Sublaminar Tethers Significantly Reduce the Risk of Proximal Junctional Failure in Surgery for Severe Adult Spinal Deformity A Propensity Score–matched Analysis

Study Design: This was a retrospective case series of prospectively collected data. Objective: The present study first described the effect of sublaminar tethering (SLT) on proximal junctional failure (PJF) in adult spinal deformity (ASD) surgery. Summary of Background Data: PJF is a devastating complication following ASD surgery. Teriparatide administration and spinous process tethering have been reported as alternatives for the prevention of PJF, but a clinically effective prevention strategy is still a matter of debate. Materials and Methods: We used data from an ASD database that included 381 patients with ASD (minimum 2-y follow-up). Among them, the data of patients who had a severe sagittal deformity and had surgery from the lower thoracic spine (T9–T11) to the pelvis were extracted and propensity score matched by age, sex, body mass index, bone mineral density, curve type, sagittal alignment, and fused level to clarify whether SLT prevented the development of PJF [SLT vs. control (CTR); age: 67 ± 7 vs. 66 ± 8 y, T-score: −1.4 ± 0.7 vs. −1.3 ± 0.6, body mass index: 22 ± 4 vs. 22 ± 5 kg/m², C7 sagittal vertical axis (C7SVA): 12 ± 7 vs. 11 ± 5 cm, pelvic incidence−lumbar lordosis (PI−LL): 51 ± 22 vs. 49 ± 21 degrees, pelvic tilt (PT): 36 ± 10 vs. 34 ± 10 degrees, level fused: 11 ± 2 vs. 11 ± 2]. Sixty-four patients were matched into 32 pairs and compared in terms of the postoperative alignment and frequency of PJF. Results: Two years postoperatively, C7SVA and PT were significantly larger in the CTR group, while no significant difference in PI−LL was found (C7SVA: 3 ± 3 vs. 6 ± 4 cm, P < 0.01, PT: 16 ± 6 vs. 24 ± 9 degrees, P < 0.01, PI−LL: 7 ± 9 vs. 11 ± 11 degrees, P = 0.22). The proximal junctional angle was significantly greater in the CTR group (proximal junctional kyphosis: 8 ± 8 vs. 17 ± 13 degrees, P < 0.01). The incidence of PJF was significantly lower in the SLT group (3% vs. 25%, P = 0.03), with an odds ratio of 0.1 (95% confidence interval: 0.0–0.8, P = 0.03). Conclusion: In the propensity score–matched cohort, the incidence of PJF was significantly lower in the SLT group. SLT is a promising procedure that may reduce the risk of PJF in severe ASD surgery.