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Michael M. Safaee, Vedat Deviren, Cecilia Dalle Ore, Justin K. Scheer, Darryl Lau, Joseph A. Osorio, Fred Nicholls, and Christopher P. Ames

proximal junctional failure (PJF), which includes radiographic evidence of PJK as well as clinical sequelae, such as pain, neurological deficit, and impaired quality of life requiring revision surgery. 8 , 24 Radiographic definitions of PJK generally require kyphosis greater than 10°–20° compared with the preoperative baseline, but there is no standardized definition. 7 , 10 , 18 Some authors have attempted to create grading and classification scales for PJK. The Boachie-Adjei classification scheme for PJK is based on the type of structural failure (1, ligamentous; 2

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Michael M. Safaee, Alexander F. Haddad, Marissa Fury, Patrick R. Maloney, Justin K. Scheer, Darryl Lau, Vedat Deviren, and Christopher P. Ames

P roximal junctional kyphosis (PJK) is a well-recognized complication after long-segment spinal fusion. The definition varies and likely falls on a spectrum that ranges from asymptomatic radiographic features to severe, symptomatic PJK with hardware failure requiring reoperation, also known as “proximal junctional failure” (PJF). 1 , 2 The radiographic definitions of PJK generally require an increase of 10° or more in the sagittal Cobb angle from the upper instrumented vertebra (UIV) to UIV+2 compared to the preoperative baseline, but there is no

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Qi Wang, Chi Wang, Xiaobo Zhang, Fanqi Hu, Wenhao Hu, Teng Li, Yan Wang, and Xuesong Zhang

. References 1 Diebo BG , Shah NV , Boachie-Adjei O , Adult spinal deformity . Lancet . 2019 ; 394 ( 10193 ): 160 – 172 . 2 Hyun SJ , Lee BH , Park JH , Proximal junctional kyphosis and proximal junctional failure following adult spinal deformity surgery . Korean J Spine . 2017 ; 14 ( 4 ): 126 – 132 . 3 Yagi M , Fujita N , Tsuji O , Low bone-mineral density is a significant risk for proximal junctional failure after surgical correction of adult spinal deformity: a propensity score-matched analysis . Spine (Phila Pa 1976) . 2018 ; 43 ( 7

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Michael M. Safaee, Cecilia L. Dalle Ore, Corinna C. Zygourakis, Vedat Deviren, and Christopher P. Ames

P roximal junctional kyphosis (PJK) is a well-recognized complication in patients undergoing surgical correction for adult spinal deformity. It presents with abnormal kyphosis immediately above the upper instrumented vertebra (UIV) and is quantified by measuring the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the second vertebral body above the UIV (UIV+2). The definition of PJK varies but is generally defined as an increase in kyphosis of more than 10°–20°. 8 , 10 , 16 We consider proximal junctional failure (PJF

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Thomas J. Buell, Davis G. Taylor, Ching-Jen Chen, Christopher I. Shaffrey, Justin S. Smith, and Shay Bess

TO THE EDITOR: We read with great interest the outstanding article by Safaee and colleagues 4 ( Safaee MM, Deviren V, Dalle Ore C, et al: Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity. J Neurosurg Spine 28 :512–519, May 2018 ). The authors compared outcomes of proximal junctional kyphosis/failure (PJK/PJF) between a historical cohort and a treatment group of adult spinal deformity (ASD) patients receiving ligamentous augmentation at the upper instrumented vertebra (UIV), 1 level

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Kee-Yong Ha, Eung-Ha Kim, Young-Hoon Kim, Hae-Dong Jang, Hyung-Youl Park, Chang-Hee Cho, Ryu-Kyoung Cho, and Sang-Il Kim

M ultilevel instrumented thoracolumbar fusion for adult spinal deformity (ASD) is performed to relieve axial pain and restore spinal alignment. 1 However, long instrumented fusion can alter the biomechanics of the spine, especially those of the unfused adjacent spinal segments. 2 Such junctional problems include adjacent-segment disease, proximal junctional kyphosis (PJK), or proximal junctional failure (PJF). 3 The incidence of PJK and PJF has been reported to vary from 13% to 70%, depending on different definitions and follow-up periods. 4

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Vibhu K. Viswanathan, Sunil Kukreja, Amy J. Minnema, and H. Francis Farhadi

months postoperatively. 30 , 34 , 59 Proximal junctional kyphosis is recognized as a harbinger of proximal junctional failure (PJF), a major complication often requiring extensive revision surgery. 22 , 26 , 51 , 57 Although various criteria have been designated for PJK, the most accepted definition includes a postoperative proximal junctional (PJ) Cobb angle value of and a relative increase of at least 10° degrees (relative to the preoperative measurement). 17 The pathogenesis underlying PJK is probably directly related to the abrupt transition between the rigid

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Vibhu K. Viswanathan, Amy J. Minnema, Stephanus Viljoen, and H. Francis Farhadi

prevention of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in ASD surgeries. Biomechanical Principles As a comparatively less rigid fixation modality that encircles cortical bone, sublaminar implants can provide various benefits in comparison to pedicle-screw-only constructs. 2 , 8 , 10 , 33 In cadaveric studies assessing the comparative pullout strengths of pedicle screws, laminar hooks, and sublaminar implants, SLBs showed a pullout load solely related to pedicle-to-vertebral body size. In contrast, pedicle screw pullout load showed a

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Vibhu K. Viswanathan, Ranjit Ganguly, Amy J. Minnema, Nicole A. DeVries Watson, Nicole M. Grosland, Douglas C. Fredericks, Andrew J. Grossbach, Stephanus V. Viljoen, and H. Francis Farhadi

P roximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-known complications following long-segment instrumented adult spinal deformity (ASD) surgery. PJK criteria include focal segmental kyphosis of 10° or more and a relative 10° or more kyphotic increase between the upper instrumented vertebra (UIV) and 2 levels cranial to the UIV (UIV+2). 7 With an incidence of 5.6%–21%, 11 , 16 PJF is the most common cause for ASD revision surgery. 24 Despite the morbidity associated with PJK and PJF, the factors underlying their development have

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Thomas J. Buell, Shay Bess, Ming Xu, Frank J. Schwab, Virginie Lafage, Christopher P. Ames, Christopher I. Shaffrey, and Justin S. Smith

print November 9, 2018. DOI: 10.3171/2018.7.SPINE171367] 30497176 9 Buell TJ , Taylor DG , Chen CJ , Shaffrey CI , Smith JS , Bess S : Proximal junctional kyphosis and proximal junctional failure . J Neurosurg Spine 29 : 610 – 611 , 2018 (Letter) 10.3171/2018.5.SPINE18636 30074445 10 Cahill PJ , Wang W , Asghar J , Booker R , Betz RR , Ramsey C , : The use of a transition rod may prevent proximal junctional kyphosis in the thoracic spine after scoliosis surgery: a finite element analysis . Spine (Phila Pa 1976) 37 : E687