Optimizing Surgical Strategies for Preventing Proximal Junctional Complications: A Systematic Review and Meta-analysis of Operative Techniques in Adult Spinal Deformity

Abstract

Objective: Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are common complications following long-segment spinal fusion, particularly in adult spinal deformity (ASD) correction surgery. Various surgical techniques have been proposed to prevent these complications, but high-quality evidence remains limited. This study aimed to evaluate the effectiveness of surgical strategies for preventing PJK and PJF after ASD correction or long-segment spinal fusion in adults. Methods: A systematic search was conducted in PubMed, Embase, and the Cochrane Library through March 2025. Eligible studies included adults who underwent ASD surgery or long-segment (≥ 4 levels) posterior spinal fusion, comparing PJK or PJF incidence across surgical techniques such as tethering, hook fixation, prophylactic vertebral augmentation, rod characteristics, and upper instrumented vertebra (UIV) level. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Results: Thirty-eight retrospective studies were included in the systematic review and 33 in the meta-analysis. Spinous process tethering reduced PJK incidence (OR, 0. 35; 95% CI, 0. 22–0. 56). Hook fixation (OR, 0. 34; 95% CI, 0. 21–0. 55) and prophylactic vertebral augmentation (OR, 0. 58; 95% CI, 0. 35–0. 95) reduced PJF incidence. Lower PJK rates were observed with UIV at T10 or above (OR, 0. 15; 95% CI, 0. 03–0. 64) and lower PJF rates with UIV at L1 or above (OR, 0. 29; 95% CI, 0. 14–0. 61). Conclusion: Surgical strategies such as tethering, hook fixation, and prophylactic vertebral augmentation may reduce the risk of PJK/PJF. Additionally, placing the UIV at or slightly above T10 may enhance junctional stability. Further prospective studies are needed to validate these findings and guide preventive strategies. © 2025 by the Korean Spinal Neurosurgery Society.