AO Spine Clinical Practice Recommendations: Proximal Junctional Kyphosis and Failure Prevention

Study DesignLiterature Review with expert consensus-based clinical practice recommendations.ObjectivesTo synthesize current evidence on risk factors and preventive strategies for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following adult spinal deformity (ASD) surgery, and to provide clinically actionable recommendations.MethodsA focused literature review was conducted by the AO Spine Knowledge Forum Deformity, identifying 30 relevant studies on PJK/PJF. Four studies were selected based on relevance to prevention strategies. Each study was critically appraised using a standardized framework. Final recommendations were established through multidisciplinary consensus using predefined criteria.ResultsPJK/PJF are multifactorial complications with reported incidence ranging from 20-40%, often occurring within the first two years postoperatively. Evidence suggests that radiographic alignment targets alone have limited predictive value for mechanical complications. Moderate-quality evidence supports the use of combined prophylactic implant strategies and avoidance of sagittal overcorrection to reduce PJF risk. Bone mineral density (BMD) consistently demonstrates a strong association with junctional complications, with lower DEXA T-scores and CT Hounsfield units at the upper instrumented vertebra correlating with increased risk. Low-quality evidence supports ligament augmentation as a junctional protection strategy, demonstrating reductions in proximal junctional angle progression and PJF incidence.ConclusionsPrevention of PJK/PJF requires a multimodal approach integrating patient biology, surgical technique, construct design, and individualized alignment goals. Based on current evidence, we recommend routine assessment and of bone quality, avoidance of sagittal overcorrection, and consideration of prophylactic junctional protection in high-risk patients. These recommendations are primarily conditional, reflecting the predominance of observational data.