Proximal Junctional Failure After Adult Spinal Deformity Surgery
Spine · 13 Aug 2026
† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.
Why it matters
PJF is a common, morbid complication of deformity surgery, and this synthesis suggests opportunistic Hounsfield unit measurement from routine preoperative CT could help surgeons flag high-risk patients before choosing fusion strategy.
The evidence
This meta-analysis pooled 28 retrospective cohort studies (4560 patients) to find predictors of proximal junctional failure (PJF) after adult spinal deformity surgery, which occurred in 23.3% of patients. PJF was linked to older age, worse baseline disability/pain, greater preoperative sagittal malalignment (higher pelvic tilt, SVA, PI-LL mismatch, lower lumbar lordosis), and poorer local bone quality, most strikingly lower CT-derived Hounsfield units at the upper instrumented vertebra (mean difference -28.97 HU) and the level above (-32.67 HU), with HU showing good diagnostic discrimination for PJF (pooled AUC 0.86). Notably, fusion length and UIV level (above/below T10) were not associated with PJF, suggesting risk depends more on alignment demands and bone competence than construct size alone.
Hounsfield units at the upper instrumented vertebra: Mean difference -28.97 (95% CI -34.04 to -23.9; units not reported). Interpret in the study's stated comparison; this alone does not establish a treatment's causal effect.
Why this rigour score?
Meta-analysis of observational studies
Methods at a glance
Recorded assessment- Comprehensive literature searchNot reported
- Risk of bias assessedNot reported
- Bias considered in synthesisNot reported
- Publication bias assessedNot reported
- Study exclusions justifiedNot reported
- Prospective registrationMet
Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.
How to read this assessment
The recorded methods are shown alongside the published score. A verified point-by-point calculation is not available for this version of the appraisal.
Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.
For journal club
1.If a patient has low Hounsfield units at the planned upper instrumented vertebra along with severe sagittal malalignment, should surgeons routinely delay surgery for bone-health optimisation or modify the construct (e.g., choosing L5 over sacral/pelvic fixation) to reduce PJF risk?
2.Given that binary osteoporosis diagnosis was not predictive but continuous DEXA T-score and CT attenuation were, should preoperative osteoporosis screening for deformity surgery shift away from a simple osteoporosis/non-osteoporosis label toward routine opportunistic HU reporting on staging CTs?
Original publication title
Proximal Junctional Failure After Adult Spinal Deformity Surgery