Mitigating Proximal Junctional Kyphosis and Failure: The Role of Tethering in a Multifactorial Problem – A Commentary on “Efficacy of Proximal Junctional Tethering in Spinal Fusion Surgery for Preventing Proximal Junctional Kyphosis and Proximal Junctional Failure: A Meta-analysis”

Niall Buckley; Ashel C. Dsouza; Lee A. Tan

doi:10.14245/ns.2551388.694

Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) have challenged spinal deformity surgery since the advent of instrumented fusion techniques, with some of the earliest descriptions reported in patients with Scheuermann’s kyphosis [1]. Attempts to mitigate PJK and PJF through proximal junctional tethering are relatively new; the first retrospective cohort study was published by Ogawa et al. [2] in 2008. Over time, it has become clear that PJK and PJF are multifactorial processes requiring attention before, during, and after surgery [3,4].

With a reported 2-year PJF incidence of 2%–18% [5], no single intervention is sufficient to eliminate the problem. Patient bone quality, dissection technique, degree of correction, construct rigidity, and postoperative rehabilitation all contribute to risk. As such, multiple strategies are being investigated, among which proximal junctional tethering has gained increasing interest. As highlighted by the authors of this study [6] and other reviews, tethering techniques vary widely: from cross-links several levels below the upper instrumented vertebra (UIV) to extensions above, and by material (polyethylene, mersilene, cadaveric semitendinosus) as well as method of proximal attachment [7]. From a cross-link several levels below the UIV to 2 levels above, tethering techniques span a variety of proximal junctional levels. The types of material (e.g., polyethylene, mersilene, cadaveric semitendinosus) and proximal attachment techniques (e.g., sublaminar, notched spinous process) are also varied.

The decreased odds of PJK and PJF observed in this study mirror the findings of Texakalidis et al. [8], who demonstrated reduced rates of these complications in 1,333 adult spinal deformity patients across 8 comparative studies with 17–31 months of follow-up. These reNeurospine sults support the ongoing exploration of tethering as part of a broader strategy. Nevertheless, the optimal approach remains undefined. While proximal junctional tethering appears promising, further prospective and stratified analyses are needed to clarify its role across different construct sizes and patient populations.

Ultimately, PJK and PJF are complex, multifactorial problems. A durable solution will likely require a comprehensive strategy that integrates careful patient selection, preservation of soft tissues during dissection, appropriate degrees of correction, thoughtful construct design, optimization of bone health, meticulous surgical technique, and attentive postoperative rehabilitation.