Dr. Pavlos Texakalidis delivers a remarkably clear and optimistic deep dive into one of the toughest problems in adult deformity surgery: how to prevent proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) after long constructs.
From the outset, Dr. Texakalidis sets the stage by precisely defining PJK as a radiographic phenomenon and PJF as the clinically relevant, symptomatic end of the same spectrum that often drives reoperations. He shows how, despite historically daunting rates, contemporary technique and implant evolution have already reduced early PJK, underscoring that this is a complication surgeons can actively influence rather than passively accept.
Risk factors and real-world patient profiles
The talk walks through familiar patient archetypes: older adults with osteoporosis, high BMI, thoracic hyperkyphosis, frailty, smoking and neurodegenerative disease who present for long deformity correction. On the surgical side, he highlights UIV selection, fixation to the sacrum/pelvis, excessive sagittal correction, combined approaches and rod stiffness as levers that can either protect the junction or push it toward failure.
Prevention before and during surgery
Dr. Texakalidis is especially strong on prevention strategy: preoperative optimization of bone density, weight, smoking status and prehabilitation, followed by meticulous UIV soft-tissue preservation and ligament protection in the OR. He translates the literature into practical choices—where to stop (L2 or below when possible, T10 or upper thoracic when necessary), how to avoid cranially directed screws that violate endplates, and how to hit age-adjusted alignment targets without overcorrection that drives junctional breakdown.
Implants, constructs, and “soft landing” concepts
A particularly motivating section reviews modern construct design: choosing cobalt chrome versus titanium rods based on the scale of correction, considering transition rods, accessory/satellite rods, and transverse process hooks to gradually step down stiffness rather than jumping from rigid fusion to mobile spine in one level. He also discusses prophylactic vertebroplasty in osteoporotic patients and presents strong meta-analytic data from his own group on posterior ligamentous tethers, which markedly reduce PJF rates even if the absolute PJK reduction is modest.
Postoperative care and the bigger picture
Dr. Texakalidis openly acknowledges the thin evidence for postoperative bracing, yet still shares the one study showing a notable drop in PJK with a hyperextension “J‑brace,” using it to emphasize how much room there is for innovation in aftercare. The session closes on a constructive note: PJK and PJF are framed not as unavoidable punishments for ambitious deformity surgery, but as biomechanical problems that can be mitigated by thoughtful planning, stress dispersion between fused and non-fused segments, and patient-specific construct design.