{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T21:13:26Z","timestamp":1793826806626,"version":"4.6.1"},"reference-count":62,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,6,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n The purpose of this study was to determine risk factors for distal junctional failure (DJF) following three-column osteotomy (3CO) for the correction of cervical deformity.<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n A retrospective review was performed of patients who underwent a cervical or upper thoracic 3CO for cervical deformity correction by the senior author from 2008 to 2023. The main outcome of interest was DJF, defined as revision surgery with extension of the distal end of the fusion construct. Patients were excluded if the lowest instrumented vertebra (LIV) was the sacrum\/pelvis, and if patients had prior autofusion throughout the distal part of the spine to the sacrum (e.g., ankylosing spondylitis). The minimum follow-up duration was 1 year.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n One hundred fourteen patients were identified who underwent a cervical or upper thoracic 3CO for cervical deformity correction, 41 of whom met inclusion criteria for this study. The median patient age was 66 years, median BMI was 27, and 61% were male. Ten patients (24%) experienced DJF, requiring reoperation and distal extension of the construct to the pelvis in 9 cases and to L1 in 1 case. On univariable analysis, patients who experienced DJF compared with those who did not were more likely to be female (80% vs 35%, p = 0.007), had lower LIV Hounsfield units (HUs; 127 vs 167, p = 0.041), were less likely to have an LIV in a small autofused segment (10% vs 45%, p = 0.02), had an LIV that was closer to the first lordotic level (one level above vs three, p = 0.043), and had a longer length of fusion (17 vs 13 levels, p = 0.033). A stepwise multivariable regression model showed that having an LIV closer to the first lordotic vertebra was the only statistically significant predictor of DJF (OR 0.49, p = 0.013) and low LIV HUs did not reach statistical significance (OR 0.97, p = 0.09).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n Patients with cervical deformity undergoing a 3CO are at higher risk for DJF with constructs terminating near the first lordotic vertebra. While LIV selection is complex and patient specific, choosing an LIV at least two levels above the first lordotic vertebra may help prevent DJF.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.1.spine241325","type":"journal-article","created":{"date-parts":[[2025,4,5]],"date-time":"2025-04-05T05:51:55Z","timestamp":1743832315000},"page":"697-704","source":"Crossref","is-referenced-by-count":2,"title":["Risk factors for distal junctional failure following three-column osteotomy for cervical deformity correction"],"prefix":"10.3171","volume":"42","author":[{"given":"Anthony L.","family":"Mikula","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Winward","family":"Choy","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zach","family":"Pennington","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexa M.","family":"Semonche","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas A.","family":"Wozny","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David J.","family":"Mazur-Hart","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaemin","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Terry H.","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aaron J.","family":"Clark","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vedat","family":"Deviren","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher P.","family":"Ames","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"6","key":"b1","series-title":"J Neurosurg Spine","first-page":"757","article-title":"Necessity of posterior osteotomies for mild flexible cervical deformity correction","volume":"41","author":"Eastlack RK","year":"2024","unstructured":"Eastlack RK, Lakomkin N, Tran S, Necessity of posterior osteotomies for mild flexible cervical deformity correction. J Neurosurg Spine. 2024;41(6):757\u2013764."},{"issue":"7","key":"b2","series-title":"J Spinal Disord Tech","first-page":"E385","article-title":"Complications and outcomes for surgical approaches to cervical kyphosis","volume":"28","author":"Grosso MJ","year":"2015","unstructured":"Grosso MJ, Hwang R, Krishnaney AA, Mroz TE, Benzel EC, Steinmetz MP. Complications and outcomes for surgical approaches to cervical kyphosis. J Spinal Disord Tech. 2015;28(7):E385\u2013E393."},{"issue":"11","key":"b3","series-title":"J Bone Joint Surg Br","first-page":"1548","article-title":"Anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis","volume":"92","author":"Song KJ","year":"2010","unstructured":"Song KJ, Johnson JS, Choi BR, Wang JC, Lee KB. Anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. J Bone Joint Surg Br. 2010;92(11):1548\u20131552."},{"issue":"7","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"771","article-title":"Surgical treatment of fixed cervical kyphosis with myelopathy","volume":"33","author":"O\u2019Shaughnessy BA","year":"2008","unstructured":"O\u2019Shaughnessy BA, Liu JC, Hsieh PC, Koski TR, Ganju A, Ondra SL. Surgical treatment of fixed cervical kyphosis with myelopathy. Spine (Phila Pa 1976). 2008;33(7):771\u2013778."},{"issue":"3","key":"b5","series-title":"Spine (Phila Pa 1976)","first-page":"143","article-title":"Comparison of Smith-Petersen osteotomy versus pedicle subtraction osteotomy versus anterior-posterior osteotomy types for the correction of cervical spine deformities","volume":"40","author":"Kim HJ","year":"2015","unstructured":"Kim HJ, Piyaskulkaew C, Riew KD. Comparison of Smith-Petersen osteotomy versus pedicle subtraction osteotomy versus anterior-posterior osteotomy types for the correction of cervical spine deformities. Spine (Phila Pa 1976). 2015;40(3):143\u2013146."},{"issue":"8","key":"b6","series-title":"Eur Spine J","first-page":"2128","article-title":"Three-column osteotomy for correction of cervical and cervicothoracic deformities: alignment changes and early complications in a multicenter prospective series of 23 patients","volume":"26","author":"Smith JS","year":"2017","unstructured":"Smith JS, Shaffrey CI, Lafage R, Three-column osteotomy for correction of cervical and cervicothoracic deformities: alignment changes and early complications in a multicenter prospective series of 23 patients. Eur Spine J. 2017;26(8):2128\u20132137."},{"issue":"2","key":"b7","series-title":"J Neurosurg Spine","first-page":"174","article-title":"Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases","volume":"15","author":"Deviren V","year":"2011","unstructured":"Deviren V, Scheer JK, Ames CP. Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases. J Neurosurg Spine. 2011;15(2):174\u2013181."},{"issue":"4","key":"b8","series-title":"Oper Neurosurg (Hagerstown)","first-page":"270","article-title":"Lower Hounsfield units at the upper instrumented vertebrae are significantly associated with proximal junctional kyphosis and failure near the thoracolumbar junction","volume":"21","author":"Mikula AL","year":"2021","unstructured":"Mikula AL, Fogelson JL, Lakomkin N, Lower Hounsfield units at the upper instrumented vertebrae are significantly associated with proximal junctional kyphosis and failure near the thoracolumbar junction. Oper Neurosurg (Hagerstown). 2021;21(4):270\u2013275."},{"issue":"5","key":"b9","series-title":"J Neurosurg Spine","first-page":"694","article-title":"Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine","volume":"37","author":"Mikula AL","year":"2022","unstructured":"Mikula AL, Lakomkin N, Pennington Z, Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine. J Neurosurg Spine. 2022;37(5):694\u2013702."},{"issue":"13","key":"b10","series-title":"Spine (Phila Pa 1976)","first-page":"922","article-title":"Evolution of proximal junctional kyphosis and proximal junctional failure rates over 10 years of enrollment in a prospective multicenter adult spinal deformity database","volume":"47","author":"Alshabab BS","year":"2022","unstructured":"Alshabab BS, Lafage R, Smith JS, Evolution of proximal junctional kyphosis and proximal junctional failure rates over 10 years of enrollment in a prospective multicenter adult spinal deformity database. Spine (Phila Pa 1976). 2022;47(13):922\u2013930."},{"issue":"6","key":"b11","series-title":"Global Spine J","first-page":"1165","article-title":"Alignment targets, curve proportion and mechanical loading: preliminary analysis of an ideal shape toward reducing proximal junctional kyphosis","volume":"12","author":"Katsuura Y","year":"2022","unstructured":"Katsuura Y, Lafage R, Kim HJ, Alignment targets, curve proportion and mechanical loading: preliminary analysis of an ideal shape toward reducing proximal junctional kyphosis. Global Spine J. 2022;12(6):1165\u20131174."},{"issue":"6","key":"b12","series-title":"J Neurosurg Spine","first-page":"752","article-title":"Reduced proximal junctional failure with ligament augmentation in adult spinal deformity: a series of 242 cases with a minimum 1-year follow-up","volume":"35","author":"Safaee MM","year":"2021","unstructured":"Safaee MM, Haddad AF, Fury M, Reduced proximal junctional failure with ligament augmentation in adult spinal deformity: a series of 242 cases with a minimum 1-year follow-up. J Neurosurg Spine. 2021;35(6):752\u2013760."},{"issue":"1","key":"b13","series-title":"Spine Deform","first-page":"38","article-title":"Preventing distal junctional kyphosis by applying the stable sagittal vertebra concept to selective thoracic fusion in adolescent idiopathic scoliosis","volume":"6","author":"Yang J","year":"2018","unstructured":"Yang J, Andras LM, Broom AM, Preventing distal junctional kyphosis by applying the stable sagittal vertebra concept to selective thoracic fusion in adolescent idiopathic scoliosis. Spine Deform. 2018;6(1):38\u201342."},{"issue":"8","key":"b14","series-title":"Clin Spine Surg","first-page":"330","article-title":"Comparison between stable sagittal vertebra and first lordotic vertebra instrumentation for prevention of distal junctional kyphosis in Scheuermann disease: systematic review and meta-analysis","volume":"32","author":"Gong Y","year":"2019","unstructured":"Gong Y, Yuan L, He M, Comparison between stable sagittal vertebra and first lordotic vertebra instrumentation for prevention of distal junctional kyphosis in Scheuermann disease: systematic review and meta-analysis. Clin Spine Surg. 2019;32(8):330\u2013336."},{"issue":"11","key":"b15","series-title":"J Bone Joint Surg Am","first-page":"1057","article-title":"Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management","volume":"93","author":"Schreiber JJ","year":"2011","unstructured":"Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):1057\u20131063."},{"issue":"1","key":"b16","series-title":"J Neurosurg Spine","first-page":"50","article-title":"Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes","volume":"32","author":"Mikula AL","year":"2019","unstructured":"Mikula AL, Puffer RC, Jeor JDS, Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes. J Neurosurg Spine. 2019;32(1):50\u201355."},{"issue":"3","key":"b17","series-title":"J Neurosurg Spine","first-page":"309","article-title":"Change in spinal bone mineral density as estimated by Hounsfield units following osteoporosis treatment with romosozumab, teriparatide, denosumab, and alendronate: an analysis of 318 patients","volume":"41","author":"Mikula AL","year":"2024","unstructured":"Mikula AL, Lakomkin N, Hamouda AM, Change in spinal bone mineral density as estimated by Hounsfield units following osteoporosis treatment with romosozumab, teriparatide, denosumab, and alendronate: an analysis of 318 patients. J Neurosurg Spine. 2024;41(3):309\u2013315."},{"key":"b18","series-title":"Global Spine J","article-title":"Paraspinal sarcopenia and lower Hounsfield units are independent predictors of increased risk for proximal junctional complications following thoracolumbar fusions terminating in the upper thoracic spine","author":"Pinter ZW","unstructured":"Pinter ZW, Bernatz J, Mikula AL, Paraspinal sarcopenia and lower Hounsfield units are independent predictors of increased risk for proximal junctional complications following thoracolumbar fusions terminating in the upper thoracic spine. Global Spine J. Published online August 1, 2024. doi:10.1177\/21925682241270094"},{"issue":"6","key":"b19","series-title":"Global Spine J","first-page":"931","article-title":"Higher paraspinal muscle density effect on outcomes after anterior cervical discectomy and fusion","volume":"11","author":"Pinter ZW","year":"2021","unstructured":"Pinter ZW, Wagner SC, Fredericks DR Jr, Higher paraspinal muscle density effect on outcomes after anterior cervical discectomy and fusion. Global Spine J. 2021;11(6):931\u2013935."},{"issue":"3","key":"b20","series-title":"J Manipulative Physiol Ther","first-page":"190","article-title":"Reliability of the Goutallier classification in quantifying muscle fatty degeneration in the lumbar multifidus using magnetic resonance imaging","volume":"37","author":"Battaglia PJ","year":"2014","unstructured":"Battaglia PJ, Maeda Y, Welk A, Hough B, Kettner N. Reliability of the Goutallier classification in quantifying muscle fatty degeneration in the lumbar multifidus using magnetic resonance imaging. J Manipulative Physiol Ther. 2014;37(3):190\u2013197."},{"issue":"12","key":"b21","series-title":"Spine J","first-page":"2187","article-title":"Predictive model for distal junctional kyphosis after cervical deformity surgery","volume":"18","author":"Passias PG","year":"2018","unstructured":"Passias PG, Vasquez-Montes D, Poorman GW, Predictive model for distal junctional kyphosis after cervical deformity surgery. Spine J. 2018;18(12):2187\u20132194."},{"issue":"1","key":"b22","series-title":"Neurosurgery","first-page":"E38","article-title":"Predicting the occurrence of postoperative distal junctional kyphosis in cervical deformity patients","volume":"86","author":"Passias PG","year":"2020","unstructured":"Passias PG, Horn SR, Oh C, Predicting the occurrence of postoperative distal junctional kyphosis in cervical deformity patients. Neurosurgery. 2020;86(1):E38\u2013E46."},{"issue":"5","key":"b23","series-title":"Eur Spine J","first-page":"1598","article-title":"Distal junctional kyphosis in adult cervical deformity patients: where does it occur?","volume":"32","author":"Ye J","year":"2023","unstructured":"Ye J, Rider SM, Lafage R, Distal junctional kyphosis in adult cervical deformity patients: where does it occur? Eur Spine J. 2023;32(5):1598\u20131606."},{"issue":"5","key":"b24","series-title":"Global Spine J","first-page":"851","article-title":"Average lumbar Hounsfield units predicts osteoporosis-related complications following lumbar spine fusion","volume":"12","author":"St Jeor JD","year":"2022","unstructured":"St Jeor JD, Jackson TJ, Xiong AE, Average lumbar Hounsfield units predicts osteoporosis-related complications following lumbar spine fusion. Global Spine J. 2022;12(5):851\u2013857."},{"issue":"2","key":"b25","series-title":"Neurosurg Focus","first-page":"E7","article-title":"The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up","volume":"49","author":"Duan PG","year":"2020","unstructured":"Duan PG, Mummaneni PV, Rivera J, The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up. Neurosurg Focus. 2020;49(2):E7."},{"issue":"5","key":"b26","series-title":"Spine (Phila Pa 1976)","first-page":"415","article-title":"Lower preoperative Hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion","volume":"38","author":"Meredith DS","year":"2013","unstructured":"Meredith DS, Schreiber JJ, Taher F, Cammisa FP Jr, Girardi FP. Lower preoperative Hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion. Spine (Phila Pa 1976). 2013;38(5):415\u2013418."},{"issue":"3","key":"b27","series-title":"Spine (Phila Pa 1976)","first-page":"E174","article-title":"Preoperative Hounsfield units at the planned upper instrumented vertebrae may predict proximal junctional kyphosis in adult spinal deformity","volume":"46","author":"Yao YC","year":"2021","unstructured":"Yao YC, Elysee J, Lafage R, Preoperative Hounsfield units at the planned upper instrumented vertebrae may predict proximal junctional kyphosis in adult spinal deformity. Spine (Phila Pa 1976). 2021;46(3):E174\u2013E180."},{"issue":"3","key":"b28","series-title":"J Bone Joint Surg Am","first-page":"206","article-title":"Impact of teriparatide on complications and patient-reported outcomes of patients undergoing long spinal fusion according to bone density","volume":"106","author":"Mohanty S","year":"2024","unstructured":"Mohanty S, Sardar ZM, Hassan FM, Lombardi JM, Lehman RA, Lenke LG. Impact of teriparatide on complications and patient-reported outcomes of patients undergoing long spinal fusion according to bone density. J Bone Joint Surg Am. 2024;106(3):206\u2013217."},{"issue":"5","key":"b29","series-title":"N Engl J Med","first-page":"412","article-title":"Romosozumab in postmenopausal women with low bone mineral density","volume":"370","author":"McClung MR","year":"2014","unstructured":"McClung MR, Grauer A, Boonen S, Romosozumab in postmenopausal women with low bone mineral density. N Engl J Med. 2014;370(5):412\u2013420."},{"issue":"5","key":"b30","series-title":"J Neurosurg Spine","first-page":"512","article-title":"Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity","volume":"28","author":"Safaee MM","year":"2018","unstructured":"Safaee MM, Deviren V, Dalle Ore C, Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity. J Neurosurg Spine. 2018;28(5):512\u2013519."},{"issue":"5","key":"b31","series-title":"Oper Neurosurg (Hagerstown)","first-page":"581","article-title":"Proximal junctional kyphosis prevention strategies: a video technique guide","volume":"13","author":"Safaee MM","year":"2017","unstructured":"Safaee MM, Osorio JA, Verma K, Proximal junctional kyphosis prevention strategies: a video technique guide. Oper Neurosurg (Hagerstown). 2017;13(5):581\u2013585."},{"issue":"6","key":"b1","series-title":"J Neurosurg Spine","first-page":"757","article-title":"Necessity of posterior osteotomies for mild flexible cervical deformity correction","volume":"41","author":"Eastlack RK","year":"2024","unstructured":"Eastlack RK, Lakomkin N, Tran S, Necessity of posterior osteotomies for mild flexible cervical deformity correction. J Neurosurg Spine. 2024;41(6):757\u2013764."},{"issue":"7","key":"b2","series-title":"J Spinal Disord Tech","first-page":"E385","article-title":"Complications and outcomes for surgical approaches to cervical kyphosis","volume":"28","author":"Grosso MJ","year":"2015","unstructured":"Grosso MJ, Hwang R, Krishnaney AA, Mroz TE, Benzel EC, Steinmetz MP. Complications and outcomes for surgical approaches to cervical kyphosis. J Spinal Disord Tech. 2015;28(7):E385\u2013E393."},{"issue":"11","key":"b3","series-title":"J Bone Joint Surg Br","first-page":"1548","article-title":"Anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis","volume":"92","author":"Song KJ","year":"2010","unstructured":"Song KJ, Johnson JS, Choi BR, Wang JC, Lee KB. Anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. J Bone Joint Surg Br. 2010;92(11):1548\u20131552."},{"issue":"7","key":"b4","series-title":"Spine (Phila Pa 1976)","first-page":"771","article-title":"Surgical treatment of fixed cervical kyphosis with myelopathy","volume":"33","author":"O\u2019Shaughnessy BA","year":"2008","unstructured":"O\u2019Shaughnessy BA, Liu JC, Hsieh PC, Koski TR, Ganju A, Ondra SL. Surgical treatment of fixed cervical kyphosis with myelopathy. Spine (Phila Pa 1976). 2008;33(7):771\u2013778."},{"issue":"3","key":"b5","series-title":"Spine (Phila Pa 1976)","first-page":"143","article-title":"Comparison of Smith-Petersen osteotomy versus pedicle subtraction osteotomy versus anterior-posterior osteotomy types for the correction of cervical spine deformities","volume":"40","author":"Kim HJ","year":"2015","unstructured":"Kim HJ, Piyaskulkaew C, Riew KD. Comparison of Smith-Petersen osteotomy versus pedicle subtraction osteotomy versus anterior-posterior osteotomy types for the correction of cervical spine deformities. Spine (Phila Pa 1976). 2015;40(3):143\u2013146."},{"issue":"8","key":"b6","series-title":"Eur Spine J","first-page":"2128","article-title":"Three-column osteotomy for correction of cervical and cervicothoracic deformities: alignment changes and early complications in a multicenter prospective series of 23 patients","volume":"26","author":"Smith JS","year":"2017","unstructured":"Smith JS, Shaffrey CI, Lafage R, Three-column osteotomy for correction of cervical and cervicothoracic deformities: alignment changes and early complications in a multicenter prospective series of 23 patients. Eur Spine J. 2017;26(8):2128\u20132137."},{"issue":"2","key":"b7","series-title":"J Neurosurg Spine","first-page":"174","article-title":"Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases","volume":"15","author":"Deviren V","year":"2011","unstructured":"Deviren V, Scheer JK, Ames CP. Technique of cervicothoracic junction pedicle subtraction osteotomy for cervical sagittal imbalance: report of 11 cases. J Neurosurg Spine. 2011;15(2):174\u2013181."},{"issue":"4","key":"b8","series-title":"Oper Neurosurg (Hagerstown)","first-page":"270","article-title":"Lower Hounsfield units at the upper instrumented vertebrae are significantly associated with proximal junctional kyphosis and failure near the thoracolumbar junction","volume":"21","author":"Mikula AL","year":"2021","unstructured":"Mikula AL, Fogelson JL, Lakomkin N, Lower Hounsfield units at the upper instrumented vertebrae are significantly associated with proximal junctional kyphosis and failure near the thoracolumbar junction. Oper Neurosurg (Hagerstown). 2021;21(4):270\u2013275."},{"issue":"5","key":"b9","series-title":"J Neurosurg Spine","first-page":"694","article-title":"Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine","volume":"37","author":"Mikula AL","year":"2022","unstructured":"Mikula AL, Lakomkin N, Pennington Z, Association between lower Hounsfield units and proximal junctional kyphosis and failure at the upper thoracic spine. J Neurosurg Spine. 2022;37(5):694\u2013702."},{"issue":"13","key":"b10","series-title":"Spine (Phila Pa 1976)","first-page":"922","article-title":"Evolution of proximal junctional kyphosis and proximal junctional failure rates over 10 years of enrollment in a prospective multicenter adult spinal deformity database","volume":"47","author":"Alshabab BS","year":"2022","unstructured":"Alshabab BS, Lafage R, Smith JS, Evolution of proximal junctional kyphosis and proximal junctional failure rates over 10 years of enrollment in a prospective multicenter adult spinal deformity database. Spine (Phila Pa 1976). 2022;47(13):922\u2013930."},{"issue":"6","key":"b11","series-title":"Global Spine J","first-page":"1165","article-title":"Alignment targets, curve proportion and mechanical loading: preliminary analysis of an ideal shape toward reducing proximal junctional kyphosis","volume":"12","author":"Katsuura Y","year":"2022","unstructured":"Katsuura Y, Lafage R, Kim HJ, Alignment targets, curve proportion and mechanical loading: preliminary analysis of an ideal shape toward reducing proximal junctional kyphosis. Global Spine J. 2022;12(6):1165\u20131174."},{"issue":"6","key":"b12","series-title":"J Neurosurg Spine","first-page":"752","article-title":"Reduced proximal junctional failure with ligament augmentation in adult spinal deformity: a series of 242 cases with a minimum 1-year follow-up","volume":"35","author":"Safaee MM","year":"2021","unstructured":"Safaee MM, Haddad AF, Fury M, Reduced proximal junctional failure with ligament augmentation in adult spinal deformity: a series of 242 cases with a minimum 1-year follow-up. J Neurosurg Spine. 2021;35(6):752\u2013760."},{"issue":"1","key":"b13","series-title":"Spine Deform","first-page":"38","article-title":"Preventing distal junctional kyphosis by applying the stable sagittal vertebra concept to selective thoracic fusion in adolescent idiopathic scoliosis","volume":"6","author":"Yang J","year":"2018","unstructured":"Yang J, Andras LM, Broom AM, Preventing distal junctional kyphosis by applying the stable sagittal vertebra concept to selective thoracic fusion in adolescent idiopathic scoliosis. Spine Deform. 2018;6(1):38\u201342."},{"issue":"8","key":"b14","series-title":"Clin Spine Surg","first-page":"330","article-title":"Comparison between stable sagittal vertebra and first lordotic vertebra instrumentation for prevention of distal junctional kyphosis in Scheuermann disease: systematic review and meta-analysis","volume":"32","author":"Gong Y","year":"2019","unstructured":"Gong Y, Yuan L, He M, Comparison between stable sagittal vertebra and first lordotic vertebra instrumentation for prevention of distal junctional kyphosis in Scheuermann disease: systematic review and meta-analysis. Clin Spine Surg. 2019;32(8):330\u2013336."},{"issue":"11","key":"b15","series-title":"J Bone Joint Surg Am","first-page":"1057","article-title":"Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management","volume":"93","author":"Schreiber JJ","year":"2011","unstructured":"Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):1057\u20131063."},{"issue":"1","key":"b16","series-title":"J Neurosurg Spine","first-page":"50","article-title":"Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes","volume":"32","author":"Mikula AL","year":"2019","unstructured":"Mikula AL, Puffer RC, Jeor JDS, Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes. J Neurosurg Spine. 2019;32(1):50\u201355."},{"issue":"3","key":"b17","series-title":"J Neurosurg Spine","first-page":"309","article-title":"Change in spinal bone mineral density as estimated by Hounsfield units following osteoporosis treatment with romosozumab, teriparatide, denosumab, and alendronate: an analysis of 318 patients","volume":"41","author":"Mikula AL","year":"2024","unstructured":"Mikula AL, Lakomkin N, Hamouda AM, Change in spinal bone mineral density as estimated by Hounsfield units following osteoporosis treatment with romosozumab, teriparatide, denosumab, and alendronate: an analysis of 318 patients. J Neurosurg Spine. 2024;41(3):309\u2013315."},{"key":"b18","series-title":"Global Spine J","article-title":"Paraspinal sarcopenia and lower Hounsfield units are independent predictors of increased risk for proximal junctional complications following thoracolumbar fusions terminating in the upper thoracic spine","author":"Pinter ZW","unstructured":"Pinter ZW, Bernatz J, Mikula AL, Paraspinal sarcopenia and lower Hounsfield units are independent predictors of increased risk for proximal junctional complications following thoracolumbar fusions terminating in the upper thoracic spine. Global Spine J. Published online August 1, 2024. doi:10.1177\/21925682241270094"},{"issue":"6","key":"b19","series-title":"Global Spine J","first-page":"931","article-title":"Higher paraspinal muscle density effect on outcomes after anterior cervical discectomy and fusion","volume":"11","author":"Pinter ZW","year":"2021","unstructured":"Pinter ZW, Wagner SC, Fredericks DR Jr, Higher paraspinal muscle density effect on outcomes after anterior cervical discectomy and fusion. Global Spine J. 2021;11(6):931\u2013935."},{"issue":"3","key":"b20","series-title":"J Manipulative Physiol Ther","first-page":"190","article-title":"Reliability of the Goutallier classification in quantifying muscle fatty degeneration in the lumbar multifidus using magnetic resonance imaging","volume":"37","author":"Battaglia PJ","year":"2014","unstructured":"Battaglia PJ, Maeda Y, Welk A, Hough B, Kettner N. Reliability of the Goutallier classification in quantifying muscle fatty degeneration in the lumbar multifidus using magnetic resonance imaging. J Manipulative Physiol Ther. 2014;37(3):190\u2013197."},{"issue":"12","key":"b21","series-title":"Spine J","first-page":"2187","article-title":"Predictive model for distal junctional kyphosis after cervical deformity surgery","volume":"18","author":"Passias PG","year":"2018","unstructured":"Passias PG, Vasquez-Montes D, Poorman GW, Predictive model for distal junctional kyphosis after cervical deformity surgery. Spine J. 2018;18(12):2187\u20132194."},{"issue":"1","key":"b22","series-title":"Neurosurgery","first-page":"E38","article-title":"Predicting the occurrence of postoperative distal junctional kyphosis in cervical deformity patients","volume":"86","author":"Passias PG","year":"2020","unstructured":"Passias PG, Horn SR, Oh C, Predicting the occurrence of postoperative distal junctional kyphosis in cervical deformity patients. Neurosurgery. 2020;86(1):E38\u2013E46."},{"issue":"5","key":"b23","series-title":"Eur Spine J","first-page":"1598","article-title":"Distal junctional kyphosis in adult cervical deformity patients: where does it occur?","volume":"32","author":"Ye J","year":"2023","unstructured":"Ye J, Rider SM, Lafage R, Distal junctional kyphosis in adult cervical deformity patients: where does it occur? Eur Spine J. 2023;32(5):1598\u20131606."},{"issue":"5","key":"b24","series-title":"Global Spine J","first-page":"851","article-title":"Average lumbar Hounsfield units predicts osteoporosis-related complications following lumbar spine fusion","volume":"12","author":"St Jeor JD","year":"2022","unstructured":"St Jeor JD, Jackson TJ, Xiong AE, Average lumbar Hounsfield units predicts osteoporosis-related complications following lumbar spine fusion. Global Spine J. 2022;12(5):851\u2013857."},{"issue":"2","key":"b25","series-title":"Neurosurg Focus","first-page":"E7","article-title":"The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up","volume":"49","author":"Duan PG","year":"2020","unstructured":"Duan PG, Mummaneni PV, Rivera J, The association between lower Hounsfield units of the upper instrumented vertebra and proximal junctional kyphosis in adult spinal deformity surgery with a minimum 2-year follow-up. Neurosurg Focus. 2020;49(2):E7."},{"issue":"5","key":"b26","series-title":"Spine (Phila Pa 1976)","first-page":"415","article-title":"Lower preoperative Hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion","volume":"38","author":"Meredith DS","year":"2013","unstructured":"Meredith DS, Schreiber JJ, Taher F, Cammisa FP Jr, Girardi FP. Lower preoperative Hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion. Spine (Phila Pa 1976). 2013;38(5):415\u2013418."},{"issue":"3","key":"b27","series-title":"Spine (Phila Pa 1976)","first-page":"E174","article-title":"Preoperative Hounsfield units at the planned upper instrumented vertebrae may predict proximal junctional kyphosis in adult spinal deformity","volume":"46","author":"Yao YC","year":"2021","unstructured":"Yao YC, Elysee J, Lafage R, Preoperative Hounsfield units at the planned upper instrumented vertebrae may predict proximal junctional kyphosis in adult spinal deformity. Spine (Phila Pa 1976). 2021;46(3):E174\u2013E180."},{"issue":"3","key":"b28","series-title":"J Bone Joint Surg Am","first-page":"206","article-title":"Impact of teriparatide on complications and patient-reported outcomes of patients undergoing long spinal fusion according to bone density","volume":"106","author":"Mohanty S","year":"2024","unstructured":"Mohanty S, Sardar ZM, Hassan FM, Lombardi JM, Lehman RA, Lenke LG. Impact of teriparatide on complications and patient-reported outcomes of patients undergoing long spinal fusion according to bone density. J Bone Joint Surg Am. 2024;106(3):206\u2013217."},{"issue":"5","key":"b29","series-title":"N Engl J Med","first-page":"412","article-title":"Romosozumab in postmenopausal women with low bone mineral density","volume":"370","author":"McClung MR","year":"2014","unstructured":"McClung MR, Grauer A, Boonen S, Romosozumab in postmenopausal women with low bone mineral density. N Engl J Med. 2014;370(5):412\u2013420."},{"issue":"5","key":"b30","series-title":"J Neurosurg Spine","first-page":"512","article-title":"Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity","volume":"28","author":"Safaee MM","year":"2018","unstructured":"Safaee MM, Deviren V, Dalle Ore C, Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity. J Neurosurg Spine. 2018;28(5):512\u2013519."},{"issue":"5","key":"b31","series-title":"Oper Neurosurg (Hagerstown)","first-page":"581","article-title":"Proximal junctional kyphosis prevention strategies: a video technique guide","volume":"13","author":"Safaee MM","year":"2017","unstructured":"Safaee MM, Osorio JA, Verma K, Proximal junctional kyphosis prevention strategies: a video technique guide. Oper Neurosurg (Hagerstown). 2017;13(5):581\u2013585."}],"container-title":["Journal of Neurosurgery: Spine"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/42\/6\/article-p697.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/42\/6\/article-p697.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-spine\/42\/6\/article-p697.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T13:44:31Z","timestamp":1772804671000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-spine\/42\/6\/article-p697.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,1]]},"references-count":62,"journal-issue":{"issue":"6"},"URL":"https:\/\/doi.org\/10.3171\/2025.1.spine241325","relation":{},"ISSN":["1547-5654"],"issn-type":[{"value":"1547-5654","type":"print"}],"subject":[],"published":{"date-parts":[[2025,6,1]]}}}