Risk Factors for Adjacent Segment Disease After Lumbar Fusion

Changju Hwang; Sung-Woo Lee; Young-Joon Ahn; Yung-Tae Kim; Dong-Ho Lee; Choon-Sung Lee

doi:10.4184/jkss.2008.15.1.44

Journal List > J Korean Soc Spine Surg > v.15(1) > 1035831

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Hwang, Lee, Ahn, Kim, Lee, and Lee: Risk Factors for Adjacent Segment Disease After Lumbar Fusion

Original Article

Journal of Korean Spine Surg 2008;15(1):44-53.

Published online: 12 February 2008

DOI: https://doi.org/10.4184/jkss.2008.15.1.44

Risk Factors for Adjacent Segment Disease After Lumbar Fusion

Changju Hwang, M.D., Sung-Woo Lee, M.D., Young-Joon Ahn, M.D.^#, Yung-Tae Kim, M.D., Dong-Ho Lee, M.D., Choon-Sung Lee, M.D.

Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea

^#National Police Hospital, Seoul, Korea

Address reprint requests to Choon-Sung Lee, M.D. Department of Orthopaedic Surgery, Asan Medical Center University of Ulsan, College of Medicine 388-1 Poongnap-dong, Songpa-gu 138-736, Seoul, Korea Tel: 82-2-3010-3530, Fax: 82-2-488-7877, E-mail: cslee@amc.seoul.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

Retrospective study of adjacent segment disease.

Objectives

To describe the incidence and clinical features of adjacent segment disease (ASD) after lumbar fusion and to determine its risk factors.

Summary of Literature Review

The reported incidence of adjacent segment problems is variable, and little has been discussed about surgically treated cases. Risk factors also have not been precisely identified, especially based on structural changes seen on magnetic resonance imaging (MRI).

Materials and Methods

We analyzed the records of 1,124 patients who underwent lumbar or lumbosacral instrumented fusions between August 1995 and March 2006 and had at least one year follow-up. Of these patients, 28 patients who needed secondary operations because of ASD were included in this study. The disease group was compared with an age-, sex-, fusion level-, and follow-up period-matched control group composed of the same number of patients, toward the purpose of analyzing six variables as risk factors.

Results

The incidence of ASD requiring surgical treatment was 2.48%. The mean patient age was 58.4 years, which showed no statistically significant difference from that of the population in which ASD did not develop (57.0 years, p=0.429). Only 1 distal ASD occurred among 21 floating fusions. Facet degeneration was a significant risk factor (p®0.01) on logistic regression analysis.

Conclusion

Our study patients with ASD complained of severe symptoms with frequent neurological abnormalities. The incidence of distal ASD was much lower than that of proximal ASD. Pre-existing facet degeneration may confer a high risk of adjacent segment problems after lumbar fusion procedures.

Keywords: Adjacent segment, Degeneration, Lumbar fusion, Risk factor

REFERENCES

1). Shono Y, Kaneda K, Abumi K, McAfee PC, Cunningham BW. Stability of posterior spinal instrumentation and its effects on adjacent motion segments in the lumbosacral spine. Spine. 1998; 23:1550–1558.

2). Bastian L, Lange U, Knop C, Tusch G, Blauth M. Evaluation of the mobility of adjacent segments after posterior thoracolumbar fixation: a biomechanical study. Eur Spine J. 2001; 10:295–300.

3). Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: Review of the literature. Spine. 2004; 29:1938–1944.

4). Ha KY, Schendel MJ, Lewis JL, et al. Effect of immobilization and configuration on lumbar adjacent-segment biomechanics. J Spinal Disord. 1993; 6:99–105.

5. Dekutoski MB, Schendel MJ, Ogilvie JW, et al. Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine. 1994; 19:1745–1751.

6). Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine. 1984; 9:574–581.

7). Cho KJ, Lee JY, Oh IS, et al. Change of segmental motion after lumbar posterolateral fusion. J Korean Orthop Assoc. 1999; 34:281–287.

8). Chung JY, Seo HY, Jung JW. Surgical treatment of adjacent degenerative segment after lumbar fusion. J Korean Spine Surg. 2000; 7:264–270.

9). Kim HT, Jang BD, Hyun KH, Nam JM. Treatment for the sequential degenerative changes at the adjacent segments to lumbar fusion. J Korean Spine Surg. 2000; 7:386–395.

10). Ha KY, Kim YH, Kang KS. Surgery for adjacent segment changes after lumbosacral fusion. J Korean Spine Surg. 2002; 9:332–340.

11). Phillips FM, Carlson GD, Bohlman HH, Hughes SS. Results of surgery for spinal stenosis adjacent to previous lumbar fusion. J Spinal Disrod. 2000; 13:432–437.

12). Chen WJ, Lai PL, Niu CC, Chen LH, Fu TS, Wong CB. Surgical treatment of adjacent instability after lumbar spine fusion. Spine. 2001; 26:519–524.

13). Aiki H, Ohwada O, Kobayashi H, et al. Adjacent segment stenosis after lumbar fusion requiring second operation. J Orthop Sci. 2005; 10:490–495.

14). Brodsky AE, Hendricks RL, Khalil MA, et al. Segmental lumbar spinal fusions. Spine. 1989; 14:447–450.

15). Pfirmann CWA, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine. 2001; 26:1873–1878.

16). Weishaupt DW, Zanetti M, Boos N, Hodler J. MR imaging and CT in osteoarthritis of the lumbar facet joints. Skeletal Radiol. 1999; 28:215–219.

17). Perdriolle R. The torsion meter: a critical review. J Pediatr Orthop. 1991; 11:789.

18). Landis RJ, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977; 33:159–174.

19). Ahn DK, Lee S, Jeong KW, Park JS, Cha SK, Park HS. Adjacent segment failure after lumbar spine fusion. J Korean Orthop Assoc. 2005; 40:203–208.

20). Rahm MD, Hall BB. Adjacent-segment degeneration after lumbar fusion with instrumentation: A retrospective study. J Spinal Disord. 1996; 9:392–400.

21). Hambly MF, Wiltse LL, Raghavan N, Schneiderman G, Koenig C. The transition zone above a lumbosacral fusion. Spine. 1998; 23:1785–1792.

22). Wiltse LL, Radecki SE, Biel HM, et al. Comparative study of the incidence and severity of degenerative change in the transition zone after instrumented versus noninstrumented fusions of the lumbar spine. J Spinal Disord. 1999; 12:27–33.

23). Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J. 2004; 4:190–194.

24). Lehmann TR, Spratt KF, Tozzi JE, et al. Long-term follow-up of lower lumbar fusion patients. Spine. 1987; 12:97–104.

25). Penta M, Sandhu A, Fraser RD. Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion. Spine. 1995; 20:743–747.

26). Okuda S, Iwasaki M, Miyauchi A, Aono H, Morita M, Yamamoto T. Risk factors for adjacent segment degeneration after PLIF. Spine. 2004; 29:1535–1540.

27). Miyakoshi N, Abe E, Shimada Y, Okuyama K, Suzuki T, Sato K. Outcome of one-level posterior lumbar interbody fusion for spondylolisthesis and postoperative intervertebral disc degeneration adjacent to the fusion. Spine. 2000; 25:1837–1842.

28). Aota Y, Kumano K, Hirabayashi S. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord. 1995; 8:464–473.

29). Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg. 1999; 90:163–169.

30). Chou WY, Hsu CJ, Chang WN, Wong CY. Adjacent segment degeneration after lumbar spinal posterolateral fusion with instrumentation in elderly patients. Arch Orthop Trauma Surg. 2002; 122:39–43.

31). Ghiselli G, Wang JC, Hsu WK, Dawson EG. L5-S1 segment survivorship and clinical outcome analysis after L4-L5 isolated fusion. Spine. 2003; 28:1275–1280.

32). Gillet P. The fate of the adjacent motion segments after lumbar fusion. J Spinal Disrod Tech. 2003; 162:338–345.

33). Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am. 2004; 86:1497–1503.

34). Pellise F, Hernandez A, Vidal X, Minguell J, Martinez C, Villanueva C. Radiologic assessment of all unfused lumbar segments 7.5 years after instrumented posterior spinal fusion. Spine. 2007; 32:574–579.

35). Ha KY, Kim KW, Park SJ, Lee YH. Changes of the adjacent-unfused mobile segment after instrumental lumbar fusion. J Korean Spine Surg. 1998; 5:205–214.

36). Frobin W, Brinckmann P, Kramer M, Hartwig E. Height of lumbar disc measured from radiographs compared with degeneration and height classified from MR images. Eur Radiol. 2001; 11:263–269.

37). Guigui P, Wodecki P, Bizot P, et al. Long-term influence of associated arthrodesis on adjacent segments in the treatment of lumbar stenosis: a series of 127 cases with 9-year follow-up. Rev Chir Orthop Reparatrice Appar Mot. 2000; 86:546–557.

38). Umehara S, Zindrick MR, Patwardhan AG, et al. The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal stenosis. Spine. 2000; 25:1617–1624.

39). Kumar MN, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J. 2001; 10:314–319.

40). Throckmorton TW, Hilibrand AS, Mencio GA, Hodge A, Spengler DM. The impact of adjacent level disc degeneration on health status outcomes following lumbar fusion. Spine. 2003; 28:2546–2550.

Fig. 1.

Imaging studies of case 1. She had degenerative spondylolisthesis at L4-5 (A, B and C). Initial radiographs and MRI demonstrate rotational deformity at L3-4, disc wedging at L2-3, and grade 4 disc degeneration at L2-3, L3-4 and L5-S1 (C). Facet degeneration was grade 2 at L2-3 (D) and grade 1 at L3-4 (E). PLIF was performed at L4-5. Adjacent segment disease developed at L2-3 and L3-4 after 33 months (F, G and H). Central spinal stenosis aggravated at L2-3 (J) and L3-4 (K). Facet joints were intact at L1-2 (I). Revision surgery was performed from L2 to L5. Note that L5-S1 segment does not show any deterioration of degeneration.

Table 1.

Classification of disc degeneration¹⁵⁾

Grade	Structure	Distinction of Nucleus and Annulus	Signal Intensity	Height of Intervertebral Disc
I	Homogeneous, bright white	Clear	Hyperintense, isointense to cerebrospinal fluid	Normal
II	Inhomogeneous with or without horizontal bands	Clear	Hyperintense, isointense to cerebrospinal fluid	Normal
III	Inhomogeneous, gray	Unclear	Intermediate	Normal to slightly decreased
IV	Inhomogeneous, gray to black	Lost	Intermediate to hypointense	Normal to moderately decreased
V	Inhomogeneous, black	Lost	Hypointense	Collapsed disc space

Table 2.

Criteria for grading osteoarthritis of the facet joints¹⁶⁾

Grade	Criteria
0	Normal facet joint space (2~4 mm width)
1	Narrowing of the facet joint space (<2 mm) and/or small osteophytes and/or mild hypertrophy of the articular process
2	Narrowing of the facet joint space and/or moderate osteophytes and/or moderate hypertrophy of the articular process and/or mild subarticular bone erosions
3	Narrowing of the facet joint space and/or large osteophytes and/or severe hypertrophy of the articular process and/or severe subarticular bone erosions and/or subchondral cysts

Table 3.

Patient profiles of disease group.

Case No	Age /Sex	Initial Diagnosis	Initial Fusion	Fusion Technique	Interval to Revision	Motor Weakness (months)	ASD	Clinical Results
1	57/F	DSL L4-5	L4-5	PLF and PLIF	133	No	SS L2-3-4	Poor
2	60/F	SS L2-3-4,	L2-3-4-5	PLF, PLIF	114	Yes	SS and HIVD	Poor
		DSL L4-5					T12-L1-2
3	69/F	HIVD L2-3,	L2-3, L4-5	PLF, PLIF	137	No	SS L3-4	Excellent
		DSL L4-5
4	57/F	SS L3-4-5	L3-4-5	PLF	199	Yes	RL and SS L2-3	Fair
5	52/F	DSL L4-5	L4-5	PLIF	198	No	AL and SS L3-4	Fair
6	65/M	DSL L3-4-5,	L3-4-5-S1	PLIF	116	Yes	RL and SS L2-3	Good
		DS, SL L5
7	66/F	SS L4-5-S1,	L4-5-S1	PLF	144	Yes	RL L2-3, SS L2-3-4	Poor
		HIVD L1-2
8	48/F	DSL L4-5	L4-5	PLF and ALIF	116	No	AL and SS L3-4	Poor
9	58/F	DSL L3-4-5	L3-4-5	PLF, PLIF	116	Yes	HIVD and SS L5-S1	Excellent
10	52/F	SS L4-5-S1	L4-5-S1	PLF, PLIF	119	No	SS L3-4	Excellent
11	55/M	DSL L3-4-5,	L3-4-5-S1	PLIF	111	Yes	SS L3-4	Good
		SS L3-4-5-S1
12	65/M	SS L2-3-4-5	L2-3-4-5	PLF, PLIF	141	Yes	RL and SS L1-2	Fair
13	50/F	RL and SS, L4-5	L4-5	PLF	168	No	AL and SS L3-4	Good
14	59/F	SS L4-5	L4-5	PLF	155	No	SS L2-3-4, RL L3-4	Good
15	48/F	DSL L4-5,	L3-4-5	PLF	176	No	AL and SS L2-3	Excellent
		SS L3-4-5
16	59/F	DSL L4-5	L4-5	PLF and PLIF	152	No	HIVD L2-3-4, AL L3-4	Excellent
17	64/M	SS L3-4-5	L3-4-5	PLF	128	Yes	SS and HIVD L2-3	Fair
18	58/M	DSL L4-5	L4-5	PLIF	126	No	HIVD and SS L3-4	Good
19	53/M	DSL L4-5	L4-5	PLF and ALIF	125	No	RL and HIVD L2-3,	Excellent
							SS L2-3-4
20	46/F	DSL L4-5,	L3-4-5	PLF, PLIF	180	No	AL and SS L2-3	Good
		SS L3-4-5
21	76/M	DSL L5-S1	L5-S1	PLIF	150	No	AL and SS L4-5	Excellent
22	61/M	ISL L5-S1,	L4-5-S1	PLF, PLIF	155	No	RL and SS	Fair
		SS L4-5-S1					L2-3-4
23	51/F	DSL L3-4,	L3-4-5	PLF, PLIF	135	No	AL, SS and HIVD	Excellent
		SS L3-4-5					L2-3
24	60/F	DSL L3-4,	L3-4-5	PLIF	159	No	AL with kyphosis	Poor
		RL L4-5				L	LL L2-3, DDS L1-2, DDS
25	53/F	DSL L4-5	L4-5	PLF	179	No	AL and SS L3-4	Excellent
26	70/M	DSL L4-5	L4-5	PLF and PLIF	150	No	SS L3-4	Good
27	64/F	DSL L4-5,	L4-5-S1	PLIF	166	No	SS L2-3-4	Fair
		SS L4-5-S1
28	60/M	SS L2-S1	L2-S1	PLF	127	Yes	AL, SS and HIVD L1-2, VCF L1	Excellent

DSL: Degenerative Spondylolisthesis, SS: Spinal Stenosis, HIVD: Herniated Intervertebral Disc, DS: Degenerative Scoliosis, SL Spondylolysis, RL: Retrolisthesis, ISL: Isthmic Spondylolisthesis, PLF: Posterolateral Fusion, PLIF: Posterior Lumbar Interbod Fusion, ALIF: Anterior Lumbar Interbody Fusion, ASD: Adjacent Segment Disease, AL: Anterolisthesis, LL: Lateral Listhesis VCF: Vertebral Compression Fracture.

Table 4.

Risk factors.

Risk Factors	Disease	Control	Logistic Regression			Fisher's Exact Test
Risk Factors	Disease	Control	p-Value	Odds Ratio	95% Confidence Interval	p-Value
Disc Degeneration	Gr 3.58	Gr 3.23	<0.17	0.48	<0.17 to 1.38
Facet Degeneration	Gr 1.58	Gr 0.92	<0.01	0.01	<0.01 to 0.12
Instability	6 cases	4 cases	<0.70	0.63	<0.06 to 6.46	0.73
Listhesis	7 cases	3 cases	<0.41	0.38	<0.04 to 3.75	0.29
Rotational Deformity	7 cases	2 cases	<0.83	0.74	<0.05 to 11.40	0.14
Disc Wedging	4 cases	2 cases	<0.63	1.81	<0.16 to 20.61	0.67

TOOLS

Similar articles