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Revision Spine Surgery
Proximal Junctional Kyphosis Revision
An in-depth, evidence-based explanation of proximal junctional kyphosis — a failure at the top of a long spinal fusion — and how it can be revised.
After a long spinal fusion, particularly for adult deformity, one of the more challenging problems that can develop is at the very top of the construct, where the fused, rigid spine meets the mobile spine above. Excessive forward angulation there is called proximal junctional kyphosis, and its more severe form, with fracture or hardware failure, is called proximal junctional failure. It can cause pain, a stooped posture and, in severe cases, neurological problems. Revising it is demanding, individualised surgery. This page explains what it is, why it happens, and how it can be treated.
For information only — not medical advice. The content on this page is patient education to help you understand a condition or treatment. It is not a substitute for personalised assessment by a qualified clinician. Always consult your doctor or specialist about your own symptoms, diagnosis, and treatment decisions.
What proximal junctional kyphosis is
Proximal junctional kyphosis (PJK) is an abnormal increase in forward angulation at the junction just above a spinal fusion. In its milder form it may be a radiological finding causing few symptoms; in its more severe form — proximal junctional failure (PJF) — there may be a fracture of the vertebra at the top of the fusion, pull-out or failure of the screws, or significant deformity and pain. It is one of the recognised challenges of long deformity fusions. Distinguishing a stable, mild PJK from a progressive or failing junction is central to deciding whether revision is needed.
Why it happens
The junction above a long fusion is a point of concentrated mechanical stress, where a stiff segment meets a mobile one. Several factors increase the risk of failure there, including weak bone (osteoporosis), the overall alignment of the spine, the condition of the muscles and soft tissues, and how the top of the construct was built. Understanding these factors matters both for preventing PJK when planning the original surgery and for planning a durable revision when it has occurred.
How revision can be done
Revising PJK or PJF is directed at restoring alignment and creating a stable, well-supported top to the construct. This usually involves extending the fusion to a higher, more suitable level, often with techniques at the new top designed to spread load and protect the next junction. Where there is significant deformity, realignment — sometimes involving osteotomies — may be needed to restore balance. Where the bone is weak, optimising bone health is part of the plan. The strategy is chosen to correct the failure while reducing the risk of the same problem recurring higher up.
What the evidence shows
The evidence characterises PJK and guides revision. Systematic reviews and meta-analyses describe its incidence and risk factors after adult deformity surgery, and studies distinguish PJK from PJF and identify the factors that predict failure. Work on revision for proximal junctional problems, and on the risk of recurrent junctional failure after fusion extension, informs how to plan a durable correction. This literature supports an individualised revision that addresses alignment, fixation and bone quality together.
What to expect
Revising proximal junctional kyphosis is major, individualised surgery, planned around the severity of the problem, the overall spinal alignment, bone health and the person's general condition. The realistic benefits, the significant risks and the alternatives are discussed thoroughly. The aim is a balanced, stable spine with a well-supported junction, and rehabilitation is tailored to the operation performed.
Disclaimer. The information provided on this page is intended for educational purposes only and should not be considered personalised medical advice. Every patient is different, and treatment options, risks, expected recovery and outcomes depend upon an individual's diagnosis, previous surgery, bone health, general health and personal circumstances. Decisions regarding treatment should always be made following consultation with your treating spinal surgeon or healthcare professional.
Evidence & further reading
- —Liu FY, et al. Risk factors for proximal junctional kyphosis after adult spinal deformity surgery: systematic review and meta-analysis. 2018. (PMID 29982856)
- —Kim HJ, et al. Proximal junctional kyphosis as adjacent segment pathology after deformity surgery: a systematic review. Spine 2012. (PMID 22885829)
- —Hostin R, et al. Incidence and risk factors for proximal junctional kyphosis: a meta-analysis. 2016. (PMID 26994925)
- —Hart RA, et al. Risk factors of PJK and PJF after long fusion to the sacrum for adult spinal deformity. Spine 2017. (PMID 28173513)
- —Risk factors for recurrent proximal junctional failure after adult spinal deformity surgery. 2024. (PMID 39107091)
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