What is Pedicle Screw Fixation (PSF) in spinal surgery?

From the Guidelines

PJF stands for Proximal Junctional Failure in spinal surgery, a serious complication that occurs above the uppermost instrumented vertebra following spinal fusion surgery. This complication involves the structural failure of the vertebral elements, which can include vertebral fracture, implant failure, or significant kyphosis at the junction between fused and non-fused segments of the spine. The use of metallic hardware instrumentation, such as titanium constructs, is a common adjuvant to spinal fusion surgery and can help establish immediate internal orthosis and protection of the neural elements 1. However, the prevention of PJF is crucial, and surgeons often take measures during initial surgery to reduce the risk. Understanding PJF is essential for both surgeons and patients when discussing the risks and benefits of spinal fusion procedures. Some key points to consider in the context of PJF include:

• The importance of using biologically inert materials, such as titanium, for hardware implants to minimize the risk of infection and other complications 1
• The need for careful patient selection and preoperative planning to reduce the risk of PJF
• The potential benefits of preventive measures, such as transition rods or prophylactic vertebroplasty, in reducing the risk of PJF
• The importance of monitoring patients for signs of PJF, such as sudden onset of pain, deformity, or neurological symptoms, and being prepared to manage the complication promptly and effectively.

From the Research

Definition of PJF in Spinal Surgery

• PJF stands for Proximal Junctional Failure, a complication that can occur after spinal surgery, particularly after long-segment posterior instrumented fusions for adult spinal deformity 2, 3, 4.
• It is characterized by mechanical failure, including vertebral fracture of the upper instrumented vertebra (UIV) or UIV+1, instability between UIV and UIV+1, and neurological deterioration requiring surgery 3.

Risk Factors for PJF

• Several risk factors have been identified, including:
  • High body mass index 3
  • Inadequate postoperative sagittal balance and overcorrection 3
  • Advanced age 3, 4
  • Pelvic instrumentation 3
  • Osteoporosis 3
  • Sarcopenia, or the loss of muscle mass and strength, particularly in the elderly population 3

Prevention Strategies for PJF

• Understanding the pathophysiology of PJF and individual risk factors is crucial for developing appropriate prevention strategies for each patient 3.
• Techniques for avoiding PJF may require refinements in both perioperative and surgical strategies, including careful planning and execution of spinal instrumentation and fusion procedures 4.
• Preventative strategies to minimize the occurrence of PJF are of tremendous importance, as progression to PJF can involve significant clinical consequences for patients and require costly revisions 2.