Estimating the risk for symptomatic adjacent segment degeneration after lumbar fusion: analysis from a cohort of patients undergoing revision surgery

Martino, Alberto Di; Quattrocchi, Carlo Cosimo; Scarciolla, Laura; Papapietro, Nicola; Zobel, Bruno Beomonte; Denaro, Vincenzo

doi:10.1007/s00586-014-3551-0

Cited by 40 publications

(25 citation statements)

References 23 publications

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“…28 In addition, a PT of > 21° and an SS of < 39° were perceived as factors for elevated risk for symptomatic ASD. 5 However, with cases of short fixation, Masevnin et al 21 failed to find statistically significant dependency between ASD and sagittal imbalance. In our study, there were no significant differences in spinal sagittal alignment between patients with and those without ASD in both groups.…”

Section: Discussionmentioning

confidence: 98%

Comparison of pedicle screw–based dynamic stabilization and fusion surgery in the treatment of radiographic adjacent-segment degeneration: a retrospective analysis of single L5–S1 degenerative spondylosis covering 4 years

Han¹,

Sun²,

Luo³

et al. 2016

SPI

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OBJECTIVE Pedicle screw–based dynamic spinal stabilization systems (PDSs) were devised to decrease, theoretically, the risk of long-term complications such as adjacent-segment degeneration (ASD) after lumbar fusion surgery. However, to date, there have been few studies that fully proved that a PDS can reduce the risk of ASD. The purpose of this study was to examine whether a PDS can influence the incidence of ASD and to discuss the surgical coping strategy for L5–S1 segmental spondylosis with preexisting L4–5 degeneration with no related symptoms or signs. METHODS This study retrospectively compared 62 cases of L5–S1 segmental spondylosis in patients who underwent posterior lumbar interbody fusion (n = 31) or K-Rod dynamic stabilization (n = 31) with a minimum of 4 years' follow-up. The authors measured the intervertebral heights and spinopelvic parameters on standing lateral radiographs and evaluated preexisting ASD on preoperative MR images using the modified Pfirrmann grading system. Radiographic ASD was evaluated according to the results of radiography during follow-up. RESULTS All 62 patients achieved remission of their neurological symptoms without surgical complications. The Kaplan-Meier curve and Cox proportional-hazards model showed no statistically significant differences between the 2 surgical groups in the incidence of radiographic ASD (p > 0.05). In contrast, the incidence of radiographic ASD was 8.75 times (95% CI 1.955–39.140; p = 0.005) higher in the patients with a preoperative modified Pfirrmann grade higher than 3 than it was in patients with a modified Pfirrmann grade of 3 or lower. In addition, no statistical significance was found for other risk factors such as age, sex, and spinopelvic parameters. CONCLUSIONS Pedicle screw–based dynamic spinal stabilization systems were not found to be superior to posterior lumbar interbody fusion in preventing radiographic ASD (L4–5) during the midterm follow-up. Preexisting ASD with a modified Pfirrmann grade higher than 3 was a risk factor for radiographic ASD. In the treatment of degenerative diseases of the lumbosacral spine, the authors found that both of these methods are feasible. Also, the authors believe that no extra treatment, other than observation, is needed for preexisting degeneration in L4–5 without any clinical symptoms or signs.

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Section: Discussionmentioning

confidence: 98%

Comparison of pedicle screw–based dynamic stabilization and fusion surgery in the treatment of radiographic adjacent-segment degeneration: a retrospective analysis of single L5–S1 degenerative spondylosis covering 4 years

Han¹,

Sun²,

Luo³

et al. 2016

SPI

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“…Some studies have suggested that abnormal sagittal spinopelvic parameters play a significant role in ASD after lumbar fusion. 5,13,14 Kumar et al reviewed 83 patients with degenerative disc disease and concluded that patients who had an abnormal C-7 plumb line position and/or SS had a significantly higher rate of ASD. 13 Di Martino et al reported that patients with PT > 20° and SS < 40° were at higher risk than others for clinically evident ASD.…”

Section: Discussionmentioning

confidence: 99%

“…7,14 Additionally, it has been suggested that spinopelvic sagittal alignment may contribute to ASD. 5,13,21 However, most of these studies of the relationships between spinopelvic sagittal alignment and ASD did not evaluate standing radiographs of the whole spine, and they included various numbers of fused segments and levels of fusion that affect spinopelvic sagittal alignment. Therefore, little is still known about the relationship between spinopelvic alignment and ASD.…”

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confidence: 99%

Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion

Matsumoto

Okuda

Maekawa

et al. 2017

SPI

121

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OBJECTIVE The importance of spinopelvic balance and its implications for clinical outcomes after spinal arthrodesis has been reported in recent studies. However, little is known about the relationship between adjacent-segment disease (ASD) after lumbar arthrodesis and spinopelvic alignment. The purpose of this study was to clarify the relationship between spinopelvic radiographic parameters and symptomatic ASD after L4–5 single-level posterior lumbar interbody fusion (PLIF). METHODS This was a retrospective 1:5 matched case-control study. Twenty patients who had undergone revision surgery for symptomatic ASD after L4–5 PLIF and had standing radiographs of the whole spine before primary and revision surgeries were enrolled from 2005 to 2012. As a control group, 100 age-, sex-, and pathology-matched patients who had undergone L4–5 PLIF during the same period, had no signs of symptomatic ASD for more than 3 years, and had whole-spine radiographs at preoperation and last follow-up were selected. Mean age at the time of primary surgery was 68.9 years in the ASD group and 66.7 years in the control group. Several radiographic spinopelvic parameters were measured as follows: sagittal vertical axis (SVA), thoracic kyphosis (TK), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), and segmental lordosis at L4–5 (SL) in the sagittal view, and C7–central sacral vertical line (C7-CSVL) in the coronal view. Radiological parameters were compared between the groups. RESULTS No significant change was found between pre- and postoperative radiographic parameters in each group. In terms of preoperative radiographic parameters, the ASD group had significantly lower LL (40.7° vs 47.2°, p < 0.01) and significantly higher PT (27° vs 22.9°, p < 0.05) than the control group. SVA ≥ 50 mm was observed in 10 of 20 patients (50%) in the ASD group and in 21 of 100 patients (21%, p < 0.01) in the control group. PI-LL ≥ 10° was noted in 15 of 20 patients (75%) in the ASD group and in 40 of 100 patients (40%, p < 0.01) in the control group on preoperative radiographs. Postoperatively, the ASD group had significantly lower TK (22.5° vs 30.9°, p < 0.01) and lower LL (39.3° vs 48.1°, p < 0.05) than the control group had. PI-LL ≥ 10° was seen in 15 of 20 patients (75%) in the ASD group and in 43 of 100 patients (43%, p < 0.01) in the control group. CONCLUSIONS Preoperative global sagittal imbalance (SVA > 50 mm and higher PT), pre- and postoperative lower LL, and PI-LL mismatch were significantly associated with ASD. Therefore, even with a single-level PLIF, appropriate SL and LL should be obtained at surgery to improve spinopelvic sagittal imbalance. The results also suggest that the achievement of the appropriate LL and PI-LL prevents ASD after L4–5 PLIF.

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“…1 The clinical outcomes of revision surgery are poor, and the many complications, especially durotomy, are more common than in primary surgery. 2,3 Several studies have evaluated the short-term results of revision 1,4 and the postoperative complications 5,6 in LSS patients after primary fusion and primary decompression. However, to our knowledge, no single-center studies with a long follow-up period and detailed analysis of outcome and risk factors for revision surgery have been conducted.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Reoperation after Fusion and after Decompression for Degenerative Lumbar Spinal Stenosis: A Single-Center Experience of 987 Cases

Kim

Park

Lim

et al. 2020

J Neurol Surg A Cent Eur Neurosurg

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Background and Study Aim Reoperation for lumbar spinal stenosis (LSS) is technically challenging. Studies comparing preoperative risk factors and reoperation outcomes between spinal fusion and spinal decompression are limited. Thus this study compared fusion and decompression with respect to reoperation rates, preoperative factors related to re-surgery, and clinical outcomes. Patients and Methods This retrospective cohort study included prospectively collected data from patients who underwent revision surgeries for degenerative LSS between May 2001 and March 2015. The reoperation rate, risk factors (proportional hazards analysis of index surgery), surgery type, main reason for revision, and final clinical outcomes (pain, quality-of-life modification, patient satisfaction, and complication rate) were analyzed and compared between the fusion and decompression surgeries. Results Among 987 cases during 13 years, 25 cases of reoperation after fusion and 23 cases of reoperation after decompression were identified, accounting for reoperation rates of 5.88% and 4.00%, respectively. Combined comorbidities (hazard ratio [HR]: 1.98 for fusion; multilevel involvement [with fusion, HR: 2.92; decompression, HR: 1.95]) were strongly correlated with preoperative demographic risk factor for each procedure. The main reason for reoperation in fusion cases was proximal junctional kyphosis (40%) and implant failure (20%), and in decompression cases, recurrent lesions (48.8%) and incomplete surgery (17.4%) An additional fusion after initial fusion and re-decompression without fusion after initial decompression were the most common surgical procedure. Back pain and patient satisfaction after fusion were better compared with those after decompression. Conclusion The reoperation rate, preoperative risk factors, reason for revision, reoperation type, clinical outcomes, patient satisfaction, and time interval between index and re-surgery were different between the primary fusion and primary decompression. A better understanding of disease pathophysiology and surgical procedure characteristics will facilitate improvement in disease management and the development of treatment strategies.

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Estimating the risk for symptomatic adjacent segment degeneration after lumbar fusion: analysis from a cohort of patients undergoing revision surgery

Abstract: In patients re-operated upon for ASD, pelvic retroversion and hyperlordosis are the main mechanisms of compensation for the unbalanced spine. Patients with PT above 21° and SS below 39° are at higher risk for symptomatic ASD.

Cited by 40 publications

References 23 publications

Comparison of pedicle screw–based dynamic stabilization and fusion surgery in the treatment of radiographic adjacent-segment degeneration: a retrospective analysis of single L5–S1 degenerative spondylosis covering 4 years

Comparison of pedicle screw–based dynamic stabilization and fusion surgery in the treatment of radiographic adjacent-segment degeneration: a retrospective analysis of single L5–S1 degenerative spondylosis covering 4 years

Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion

Comparison of Reoperation after Fusion and after Decompression for Degenerative Lumbar Spinal Stenosis: A Single-Center Experience of 987 Cases

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