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Updated: Jun 19, 2026

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity
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Machine learning-based identification of distinct risk factors for moderate versus severe proximal junctional

Dong-Ho Kang1, Jin-Sung Park1, Chong-Suh Lee2

  • 1Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea.

The Spine Journal : Official Journal of the North American Spine Society
|June 17, 2026
PubMed
Summary

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Machine learning identified distinct risk factors for moderate and severe proximal junctional kyphosis (PJK) after adult spinal deformity surgery. Moderate PJK is linked to geometric stress, while severe PJK relates to construct issues, guiding tailored prevention.

Area of Science:

  • Spine surgery
  • Biomechanical engineering
  • Data science in medicine

Background:

  • Proximal junctional kyphosis (PJK) is a common complication following adult spinal deformity (ASD) surgery.
  • Existing thresholds for PJK may not fully capture distinct clinical presentations and underlying causes.

Purpose of the Study:

  • To utilize machine learning to identify and compare predictive risk factors for moderate (PJA ≥15°) and severe (PJA ≥28°) PJK.
  • To differentiate the etiologies of moderate versus severe PJK.

Main Methods:

  • A retrospective analysis of 374 patients undergoing ASD surgery with a minimum 2-year follow-up.
  • Training five machine learning algorithms (Logistic Regression, SVM, RF, XGBoost, AutoGluon) to predict moderate and severe PJK.
  • Employing feature stability and SHAP analyses to identify robust predictors and their directional impact.
Keywords:
Adult spinal deformityMachine learningProximal junctional failureProximal junctional kyphosisRisk factorsSagittal alignment

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Main Results:

  • The incidence of moderate and severe PJK was 17.4% and 11.0%, respectively.
  • Body Mass Index (BMI) and L1 tilt were key predictors for moderate PJK, with relative hyperlordosis (RLL) increasing risk and iliac screws offering protection.
  • Maldistributed lordosis (LDI) and construct rigidity (number of rods) predicted severe PJK, alongside excessive postoperative lordosis (LL) and high cement volume.

Conclusions:

  • Moderate PJK is associated with geometric stress concentration, influenced by factors like L1 tilt and RLL.
  • Severe PJK is linked to structural and distributional mismatches within the spinal construct, such as LDI and construct rigidity.
  • Prevention strategies for PJK should be tailored based on these distinct underlying mechanisms.