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Proximal Junctional Failure After Adult Spinal Deformity Surgery: A Systematic Review and Meta-analysis of Predictive
Shaan Patel1, Shiva A Nischal2, Griffin W White3
1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
Spine
|August 13, 2026
Summary
Proximal junctional failure (PJF) after adult spinal deformity (ASD) surgery is linked to older age and sagittal misalignment. Opportunistic CT bone density measurements show promise for predicting PJF risk.
Area of Science:
- Spine surgery outcomes research
- Orthopedic biomechanics
- Radiology and medical imaging
Background:
- Proximal junctional failure (PJF) is a significant complication following adult spinal deformity (ASD) surgery, leading to pain, progressive deformity, and reoperation.
- Existing research on predictive risk factors for PJF is inconsistent, and the clinical utility of opportunistic bone quality assessment remains unclear.
Purpose of the Study:
- To identify patient-related, operative, radiographic, and bone quality factors predicting PJF after ASD surgery.
- To evaluate the diagnostic performance of CT-derived bone quality metrics for predicting PJF.
Main Methods:
- Systematic review and meta-analysis of observational studies reporting PJF after ASD surgery.
- Searched PubMed, Embase, and CENTRAL databases.
- Analyzed diagnostic accuracy of Hounsfield unit measurements using pooled sensitivity, specificity, and AUC.
Main Results:
- Included 28 studies with 4560 patients; 23.3% developed PJF.
- PJF associated with older age, worse baseline disability/pain, and greater sagittal misalignment.
- Continuous bone measures (DEXA T-scores, CT attenuation) and Hounsfield units (AUC 0.86) were predictive; binary osteoporosis was not consistently associated.
Conclusions:
- PJF results from an interplay of sagittal alignment, surgical strategy, and structural integrity.
- Opportunistic Hounsfield unit assessment shows potential for PJF risk stratification in vulnerable patients.
- Prospective validation is needed to confirm the utility of bone quality measures in preventing PJF.
