Risk Factor Analysis for Proximal Junctional Kyphosis in Neuromuscular Scoliosis: A Single-Center Study

<b>Background/Objectives:</b> Proximal junctional kyphosis (PJK) is one of the most frequently discussed complications following corrective surgery in patients with neuromuscular scoliosis (NMS). Despite its clinical relevance, the etiology of PJK remains incompletely understood and appears to be multifactorial. Biomechanical and limited clinical studies suggest that preoperative hyperkyphosis, resection of the spinous processes with consequent disruption of posterior ligamentous structures, and rod contouring parameters may contribute as risk factors. <b>Methods</b>: To validate these findings, we retrospectively analyzed 99 NMS patients who underwent posterior spinal fusion using a standardized screw-rod system between 2009 and 2017. Radiographic assessments were conducted at three time points: preoperatively (preOP), postoperatively (postOP), and at a mean follow-up (FU) of 29 months. Clinical variables collected included patient age, weight, height, sex, and Risser sign. Radiographic evaluations encompassed Cobb angles, thoracic kyphosis (TK), lumbar lordosis, the levels of the upper (UIV) and lower (LIV) instrumented vertebrae, the total number of fused segments, parameters of sagittal alignment, the rod contour angle (RCA), and the postoperative mismatch between RCA and the proximal junctional angle (PJA). Based on the development of proximal junctional kyphosis, patients were categorized into PJK and non-PJK groups. <b>Results</b>: The overall incidence of PJK was 23.2%. In line with previous biomechanical findings, spinous process resection was significantly associated with PJK development. Furthermore, the PJK group demonstrated significantly higher preoperative TK (59.3° ± 29.04° vs. 34.5° ± 26.76°, <i>p</i> < 0.001), greater RCA (10.2° ± 4.01° vs. 7.7° ± 4.34°, <i>p</i> = 0.021), and a larger postoperative mismatch between PJA and RCA (PJA-RCA: 3.8° ± 6.76° vs. -1.8° ± 6.55°, <i>p</i> < 0.001) compared to the non-PJK group. <b>Conclusions</b>: Spinous process resection, a pronounced mismatch between postoperative PJA and RCA (odds ratio [OR] = 1.19, <i>p</i> = 0.002), excessive rod bending (i.e., high RCA), and severe preoperative thoracic hyperkyphosis with an expected increase in the risk of PJK of approximately 6.5% per degree of increase in preoperative TK are significant risk factors for PJK. These variables should be carefully considered during the surgical planning and execution of deformity correction in NMS patients.