Preoperative alignment and risk of proximal junctional failure

作者：Jeffrey M. Hills, Lawrence G. Lenke, Justin S. Smith, Christopher I. Shaffrey, Virginie Lafage, Renaud Lafage, Shay Bess, Michael P. Kelly · 发表于：The Bone & Joint Journal · 年份：2026 · DOI：10.1302/0301-620x.108b7.bjj-2025-1405.r1 · 研究领域：Scoliosis diagnosis and treatment、Cervical and Thoracic Myelopathy、Spine and Intervertebral Disc Pathology

Aims: Proximal junctional kyphosis (PJK) remains a major complication after surgery for adult spinal deformity (ASD). While postoperative alignment is a recognized modifiable risk factor, objective methods for selecting the upper instrumented vertebra (UIV), a key modifiable factor, are lacking. We aimed to determine whether preoperative sagittal alignment, specifically cervicothoracic alignment, predicts the risk of PJK, and whether this risk can be mitigated by UIV selection, focusing on factors available at the time of surgical planning. Methods: From a multicentre, prospective ASD registry, we identified patients who had undergone fusion to the sacrum or pelvis and had an upper (T1-T5) or lower thoracic (T9-L1) UIV, with a two-year or more radiological follow-up, excluding those with a previous fusion over more than four levels. The primary outcome was PJK within two years. Multivariable logistic regression modelled the risk of PJK by UIV region, preoperative C2-T9 pelvic angle (PA), age, sex, and pelvic incidence, testing for interaction between UIV region and C2-T9 PA. Adjusted absolute risk reduction (ARR) and number needed to be exposed (NNEB) were calculated. Multivariable linear regression estimated two-year patient-reported outcome measures, adjusting for baseline scores, age, UIV, and PJK. Results: A total of 627 patients across 20 centres were included (median age 66 years (IQR 59 to 70); 483 (77%) female). The UIV was lower thoracic in 380 (61%) and upper thorac...