Journal List > J Korean Soc Spine Surg > v.9(4) > 1036036

Ha, Kim, and Kang: Surgery for Adjacent Segment Changes after Lumbosacral Fusion

Abstract

Purpose

To report upon surgical outcome in terms of adjacent segment changes after lumbosacral fusion and to analyze for risk factors indicating early surgical intervention for adjacent segment changes.

Material and Methods

This was a retrospective study of twenty patients who underwent revision surgery for adjacent segment changes after lumbosacral fusion. Inclusion criteria were as follows: 1) minimum 24 months follow- up, 2) confirmed adjacent segment changes by CT- myelogram or MRI, 3) conservative treatment for at least 3months, 4) available preoperative X-ray films and 5) posterolateral fusions at a prior fusion. Correlation analysis was performed for age, sex, the number of fused levels, grade of radiographic degeneration and instrumentation using the independent sample t- Test.

Results

A ge, sex, the number of fused levels, the use of instrumentation and the preservation of lumbar lordosis were not correlated with the interval to revision (IR). However, the grade of radiographic degeneration (plain film and CT) were highly correlated with IR (R= - 0.699, - 0.654). Degenerative scoliosis had a shorter IR, with statistical significance (P<0.05), than other disease examined. Excellent and good clinical results were obtained in 14 patients (60%), and solid bony fusion was achieved in 18 patients (90%).

Conclusions

When deciding upon fusion level, especially in cases of degenerative scoliosis, the need for caution could not be overemphasized. The grade of radiographic degeneration provides a useful indicator for predicting earlier adjacent segment changes.

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Fig. 1.
A 50-year-old female's radiographs (Case #3). (A) Immediate postoperative radiographs shows Kellgren grade III degeneration at L2, 3 level with L3-5 fusion for degenerative spondylolisthesis. (B) At postoperative 8 years, complete block at the adjacent segment is noted on myelogram. (C) For the adjacent segment stenosis, revision surgery was done with L1-3 fusion.
jkss-9-332f1.tif
Fig. 2.
A 62-year-old male's radiographs (Case #9). (A, B) Decompression and posterolateral fusion including L3-5 was done and then (C) revision fusion was done for adjacent segment stenosis after 5 years later. Solid fusion on the L3-5 area and revision fusion with pedicular screw on L1-3 was noted. One year later, he revisited with the complaint of severe low back pain with no history of injury. (D) Computed tomographic scan demonstrates the bilateral pedicle fracture involving L4 and then marginal sclerosis and irregularity of the fracture line suggests it as a stress fracture.
jkss-9-332f2.tif
Fig. 3.
A 63-year-old female's radiographs (Case #10). (A) Initial radiographs shows degenerative lumbar scoliosis and multiple disc wedging, but L2, 3 disc space is relatively preserved. (B) Kellgren grade III degeneration is noted at L2, 3 level on immediate postoperative radiographs. (C) At postoperative 6 years, severe disc collapsing is noted. (D) Extended fusion to L1 was done. Clinically she complains of frequent back pain without neurological symptoms.
jkss-9-332f3.tif
Table 1.
Patients Demographics
Case No. Age/ Sex Initial Dx Interval to Revision (months) Initial No. of fusion levels Kellgren Grade CTN Grade Instumentation (1° operation) Lumbar Lordosis (°) Remarks
1 81/F SS 62 2 I I No 15 Retrolisthesis
2 59/F SS,SPL 48 1 I I Yes 48 Listhesis
3 50/F SPL 96 2 III III Yes 20 Listhesis
4 57/F SS 72 1 II II No -2  
5 64/M SS 105 2 II III No 45 Retrolisthesis
6 61/F SS 102 1 II II Yes 10  
7 58/F SS 72 2 I I Yes 36 Listhesis
8 70/F SS 48 2 III II No 20  
9 62/M DS 60 2 II III Yes 25 Pedicle stress fracture
10 63/F DS 72 2 III IV Yes 1  
11 62/F SS 86 1 II III No 45 Retrolisthesis
12 71/F SPL 192 3 IV IV Yes 30 Retrolisthesis
13 67/F SS 120 3 II II Yes 25 Retrolisthesis
14 65/F DS 48 2 IV IV No 10 Listhesis
15 70/F DS 36 4 I I No 40  
16 53/F DS 39 3 III III Yes 0  
17 63/F SS 49 2 I I Yes 30 Retrolisthesis
18 67/M SPL 57 1 I I No 45 Retrolisthesis
19 68/M DS 36 3 II II Yes 35 Listhesis
20 70/F SPL 62 2 I II No 36 Retrolisthesis

SS: Spinal stenosis, SPL: Spondylolisthesis, DS: Degenerative scoliosis, Lordosis: (-) mean kyphosis.

Table 2.
Radiologic grading of adjacent segment degeneration (prior to 1° surgery).
Kellgren Grade: Grade 1: Minimal osteophytosis only
  Grade 2: Definite osteophytosis with some sclerosis of anterior part of vertebral plates
  Grade 3: Marked osteophytosis and sclerosis of vertebral plates with slight narowing of disc space.
  Grade 4: Large osteophytosis, marked sclerosis of vertebral plates and marked narrowing of disc space
CT Grade Grade 1: Normal to minimal osteophytosis only
  Grade 2: Definite osteophytosis
  Grade 3: Marked osteophytosis and facet arthritis
  Grade 4: Marked osteophytosis, facet arthritis and Knuttson's sign
Table 3.
Brodsky's criteria
Designation Criterion
Excellent No pain
Good Occasional back or leg pain No change of work No change of leisure activity
Fair Frequent back or leg pain Some change of work Some change of leisure activity
Poor Disabling pain Long-term medication Unable to work
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