Instrumentation Techniques to Prevent Proximal Junctional Kyphosis and Proximal Junctional Failure in Adult Spinal Deformity Correction: A Systematic Review of Clinical Studies

T.F.G. Vercoulen*, R.J.P. Doodkorte, A. Roth, R. de Bie, P.C. Willems

*Corresponding author for this work

Research output: Contribution to journal(Systematic) Review article peer-review


Study Design: Systematic review.Objectives: To summarize the results of clinical studies investigating spinal instrumentation techniques aiming to reduce the postoperative incidence of proximal junctional kyphosis (PJK) and/or failure (PJF) in adult spinal deformity (ASD) patients.Methods: EMBASE and Medline (R) were searched for articles dating from January 2000 onward. Data was extracted by 2 independent authors and methodological quality was assessed using ROBINS-I.Results: 18 retrospective- and prospective cohort studies with a severe or critical risk of bias were included. Different techniques were applied at the upper instrumented vertebra (UIV): tethers in various configurations, 2-level prophylactic vertebroplasty (2-PVP), transverse process hooks (TPH), flexible rods (FR), sublaminar tapes (ST) and multilevel stabilization screws (MLSS). Compared to a pedicle screw (PS) group, significant differences in PJK incidence were found using tethers in various configurations (18% versus 45%, P = 0.001, 15% versus 38%, P = 0.045), 2-PVP (24% vs 36%, P = 0.020), TPH (0% vs. 30%, P = 0.023) and FR (15% versus 38%, P = 0.045). Differences in revision rates for PJK were found in studies concerning tethers (4% versus 18%, P = 0.002), 2-PVP (0% vs 13%, P = 0.031) and TPH (0% vs 7%, P = n.a.).Conclusion: Although the studies are of low quality, the most frequently studied techniques, namely 2-PVP as anterior reinforcement and (tensioned) tethers or TPH as posterior semi-rigid fixation, show promising results. To provide a reliable comparison, more controlled studies need to be performed, including the use of clinical outcome measures and a uniform definition of PJF.
Original languageEnglish
Article number21925682211034500
Pages (from-to)1282-1296
Number of pages15
JournalGlobal Spine Journal
Issue number6
Early online date30 Jul 2021
Publication statusPublished - Jul 2022


  • long-segment spinal fusion
  • adult spinal deformity
  • spine surgery
  • proximal junctional kyphosis
  • proximal junctional failure
  • systematic review
  • topping-off
  • transition zone
  • semi-rigid junctional fixation

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