{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,15]],"date-time":"2026-01-15T09:38:57Z","timestamp":1768469937624,"version":"3.49.0"},"reference-count":26,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,9,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>Multiple rods are utilized in adult spinal deformity (ASD) surgery to increase construct stiffness. However, the impact of multiple rods on proximal junctional kyphosis (PJK) is not well established. This study aimed to investigate the impact of multiple rods on PJK incidence in ASD patients.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>ASD patients from a prospective multicenter database with a minimum follow-up of 1 year were retrospectively reviewed. Clinical and radiographic data were collected preoperatively, at 6 weeks postoperatively, at 6 months postoperatively, at 1 year postoperatively, and at every subsequent year postoperatively. PJK was defined as a kyphotic increase of &gt; 10\u00b0 in the Cobb angle from the upper instrumented vertebra (UIV) to UIV+2 as compared with preoperative values. Demographic data, radiographic parameters, and PJK incidence were compared between the multirod and dual-rod patient cohorts. PJK-free survival analysis was performed using Cox regression to control for demographic characteristics, comorbidities, level of fusion, and radiographic parameters.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>Overall, 307\/1300 (23.62%) cases utilized multiple rods. Cases with multiple rods were more likely to be revisions (68.4% vs 46.5%, p &lt; 0.001), to be posterior only (80.7% vs 61.5%, p &lt; 0.001), involve more levels of fusion (mean 11.73 vs 10.60, p &lt; 0.001), and include 3-column osteotomy (42.9% vs 17.1%, p &lt; 0.001). Patients with multiple rods also had greater preoperative pelvic retroversion (mean pelvic tilt 27.95\u00b0 vs 23.58\u00b0, p &lt; 0.001), greater thoracolumbar junction kyphosis (\u221215.9\u00b0 vs \u221211.9\u00b0, p = 0.001), and more severe sagittal malalignment (C7\u2013S1 sagittal vertical axis 99.76 mm vs 62.23 mm, p &lt; 0.001), all of which corrected postoperatively. Patients with multiple rods had similar incidence rates of PJK (58.6% vs 58.1%) and revision surgery (13.0% vs 17.7%). The PJK-free survival analysis demonstrated equivalent PJK-free survival durations among the patients with multiple rods (HR 0.889, 95% CI 0.745\u20131.062, p = 0.195) after controlling for demographic and radiographic parameters. Further stratification based on implant metal type demonstrated noninferior PJK incidence rates with multiple rods in the titanium (57.1% vs 54.6%, p = 0.858), cobalt chrome (60.5% vs 58.7%, p = 0.646), and stainless steel (20% vs 63.7%, p = 0.008) cohorts.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>Multirod constructs for ASD are most frequently utilized in revision, long-level reconstructions with 3-column osteotomy. The use of multiple rods in ASD surgery does not result in an increased incidence of PJK and is not affected by rod metal type.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2023.4.spine23209","type":"journal-article","created":{"date-parts":[[2023,6,10]],"date-time":"2023-06-10T17:36:07Z","timestamp":1686418567000},"page":"320-328","source":"Crossref","is-referenced-by-count":9,"title":["Use of multiple rods and proximal junctional kyphosis in adult spinal deformity surgery"],"prefix":"10.3171","volume":"39","author":[{"given":"Jichao","family":"Ye","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sachin","family":"Gupta","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ali S.","family":"Farooqi","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tsung-Cheng","family":"Yin","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alex","family":"Soroceanu","sequence":"additional","affiliation":[{"name":"University of Calgary Spine Program, University of Calgary, Alberta, Canada;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frank J.","family":"Schwab","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Virginie","family":"Lafage","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael P.","family":"Kelly","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Khaled","family":"Kebaish","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard","family":"Hostin","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeffrey L.","family":"Gum","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Justin S.","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher I.","family":"Shaffrey","sequence":"additional","affiliation":[{"name":"Departments of Neurological Surgery and Orthopedic Surgery, Division of Spine Surgery, Duke University, Durham, North Carolina;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Justin K.","family":"Scheer","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Themistocles S.","family":"Protopsaltis","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter G.","family":"Passias","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eric O.","family":"Klineberg","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, University of California Davis, Sacramento, California;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Han Jo","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert A.","family":"Hart","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"D. Kojo","family":"Hamilton","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christopher P.","family":"Ames","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Munish C.","family":"Gupta","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"5","key":"b1","series-title":"J Neurosurg Spine","first-page":"551","article-title":"Treatment of adult thoracolumbar spinal deformity: past, present, and future","volume":"30","author":"Smith JS","year":"2019","unstructured":"Smith JS, Shaffrey CI, Ames CP, Lenke LG. 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Fate of the adult revision spinal deformity patient: a single institution experience. Spine (Phila Pa 1976). 2013;38(19):E1196\u2013E1200."},{"issue":"9","key":"b7","series-title":"Spine J","first-page":"1612","article-title":"Rod fracture in adult spinal deformity surgery fused to the sacrum: prevalence, risk factors, and impact on health-related quality of life in 526 patients","volume":"18","author":"Lertudomphonwanit T","year":"2018","unstructured":"Lertudomphonwanit T, Kelly MP, Bridwell KH,  Rod fracture in adult spinal deformity surgery fused to the sacrum: prevalence, risk factors, and impact on health-related quality of life in 526 patients. 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Rod stiffness as a risk factor of proximal junctional kyphosis after adult spinal deformity surgery: comparative study between cobalt chrome multiple-rod constructs and titanium alloy two-rod constructs. Spine J. 2017;17(7):962\u2013968."},{"issue":"3","key":"b15","series-title":"Asian Spine J","first-page":"500","article-title":"Multi-rod constructs can increase the incidence of iliac screw loosening after surgery for adult spinal deformity","volume":"13","author":"Banno T","year":"2019","unstructured":"Banno T, Hasegawa T, Yamato Y,  Multi-rod constructs can increase the incidence of iliac screw loosening after surgery for adult spinal deformity. Asian Spine J. 2019;13(3):500\u2013510."},{"issue":"9","key":"b16","series-title":"Spine (Phila Pa 1976)","first-page":"1064","article-title":"Intra-observer reproducibility and interobserver reliability of the radiographic parameters in the Spinal Deformity Study Group\u2019s AIS Radiographic Measurement Manual","volume":"30","author":"Dang NR","year":"2005","unstructured":"Dang NR, Moreau MJ, Hill DL, Mahood JK, Raso J. Intra-observer reproducibility and interobserver reliability of the radiographic parameters in the Spinal Deformity Study Group\u2019s AIS Radiographic Measurement Manual. 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Neurospine. 2020;17(2):466\u2013470."},{"issue":"3","key":"b18","series-title":"Spine Deform","first-page":"481","article-title":"Long additional rod constructs can reduce the incidence of rod fractures following 3-column osteotomy with pelvic fixation in short term","volume":"8","author":"Yamato Y","year":"2020","unstructured":"Yamato Y, Hasegawa T, Togawa D,  Long additional rod constructs can reduce the incidence of rod fractures following 3-column osteotomy with pelvic fixation in short term. Spine Deform. 2020;8(3):481\u2013490."},{"issue":"4","key":"b19","series-title":"Eur Spine J","first-page":"886","article-title":"Multiple-rod constructs in adult spinal deformity surgery for pelvic-fixated long instrumentations: an integral matched cohort analysis","volume":"29","author":"Guevara-Villaz\u00f3n F","year":"2020","unstructured":"Guevara-Villaz\u00f3n F, Boissiere L, Hayashi K,  Multiple-rod constructs in adult spinal deformity surgery for pelvic-fixated long instrumentations: an integral matched cohort analysis. Eur Spine J. 2020;29(4):886\u2013895."},{"issue":"14","key":"b20","series-title":"Spine (Phila Pa 1976)","first-page":"1643","article-title":"Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis","volume":"30","author":"Glattes RC","year":"2005","unstructured":"Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C II. 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Neurosurgery. 2017;80(2):279\u2013286."},{"issue":"4","key":"b22","series-title":"Spine (Phila Pa 1976)","first-page":"258","article-title":"Effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of sagittal alignment overcorrection","volume":"45","author":"Line BG","year":"2020","unstructured":"Line BG, Bess S, Lafage R,  Effective prevention of proximal junctional failure in adult spinal deformity surgery requires a combination of surgical implant prophylaxis and avoidance of sagittal alignment overcorrection. Spine (Phila Pa 1976). 2020;45(4):258\u2013267."},{"issue":"2","key":"b23","series-title":"Neurosurg Rev","first-page":"855","article-title":"Incidence and risk factors of proximal junctional kyphosis after internal fixation for adult spinal deformity: a systematic evaluation and meta-analysis","volume":"44","author":"Zhao J","year":"2021","unstructured":"Zhao J, Chen K, Zhai X, Chen K, Li M, Lu Y. Incidence and risk factors of proximal junctional kyphosis after internal fixation for adult spinal deformity: a systematic evaluation and meta-analysis. Neurosurg Rev. 2021;44(2):855\u2013866."},{"key":"b24","series-title":"World Neurosurg","first-page":"404","article-title":"Comparative study between cobalt chrome and titanium alloy rods for multilevel spinal fusion: proximal junctional kyphosis more frequently occurred in patients having cobalt chrome Rods","volume":"103","author":"Han S","year":"2017","unstructured":"Han S, Hyun SJ, Kim KJ, Jahng TA, Kim HJ. Comparative study between cobalt chrome and titanium alloy rods for multilevel spinal fusion: proximal junctional kyphosis more frequently occurred in patients having cobalt chrome Rods. World Neurosurg. 2017;103:404\u2013409."},{"issue":"2","key":"b25","series-title":"Oper Neurosurg (Hagerstown)","first-page":"E163","article-title":"Kickstand rod technique for correcting coronal imbalance in adult scoliosis: 2-dimensional operative video","volume":"19","author":"Buell TJ","year":"2020","unstructured":"Buell TJ, Buchholz AL, Mazur MD,  Kickstand rod technique for correcting coronal imbalance in adult scoliosis: 2-dimensional operative video. Oper Neurosurg (Hagerstown). 2020;19(2):E163\u2013E164."},{"issue":"10","key":"b26","series-title":"Spine J","first-page":"S216","article-title":"Redefining radiographic thresholds for junctional kyphosis pathologies","volume":"15","author":"Lafage R","year":"2015","unstructured":"International Spine Study Group; Lafage R, Schwab FJ, Bess S,  Redefining radiographic thresholds for junctional kyphosis pathologies. 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