• Thomas J Buell, Avery L Buchholz, John C Quinn, Shay Bess, Breton G Line, Christopher P Ames, Frank J Schwab, Virginie Lafage, Christopher I Shaffrey, and Justin S Smith.
• Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.
• Oper Neurosurg (Hagerstown). 2019 Feb 1; 16 (2): 256-266.

BackgroundProximal junctional kyphosis (PJK) is a common problem after multilevel spine instrumentation.ObjectiveTo determine if junctional tethers reduce PJK after multilevel instrumented surgery for adult spinal deformity (ASD).MethodsASD patients who underwent posterior instrumented fusion were divided into 3 groups: no tether (NT), polyethylene tether-only (TO; tied securely through the spinous processes of the uppermost instrumented vertebra [UIV] + 1 and UIV-1), and tether with crosslink (TC; passed through the spinous process of UIV+1 and tied to a crosslink between UIV-1 and UIV-2). PJK was defined as proximal junctional angle ≥ 10° and ≥ 10° greater than the corresponding preoperative measurement.ResultsOne hundred eighty-four (96%) of 191 consecutive patients achieved minimum 3-mo follow-up (mean = 20 mo [range:3-56 mo]; mean age = 66 yr; 67.4% female). There were no significant differences between groups based on demographic, surgical, and sagittal radiographic parameters. PJK rates were 45.3% (29/64), 34.4% (22/64), and 17.9% (10/56) for NT, TO, and TC, respectively. PJK rate for all tethered patients (TO + TC; 26.7% [32/120]) was significantly lower than NT (P = .011). PJK rate for TC was significantly lower than NT (P = .001). Kaplan-Meier analysis showed significant time-dependent PJK reduction for TC vs NT (log rank test, P = .010). Older age and greater change in lumbar lordosis were independent predictors of PJK, while junctional tethers had a significant protective effect.ConclusionJunctional tethers significantly reduced occurrence of PJK. This difference was progressive from NT to TO to TC, but only reached pairwise significance for NT vs TC. This suggests potential benefit of tethers to reduce PJK, and that future prospective studies are warranted.

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