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%).
REFERENCES
1). Aota Y, Kumano K and Hirabayashi S. Pos tfus ion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord. 8:464–473. 1995.
2). Bastian L, Lange Uta, Knop C, Tusch G and Blauth M. Evaluation of the mobility of adjacent segments after posterior thoracolumbar fixation: A biomechanical study. Eur Spine J. 10:295–300. 2001.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
3). Brodsky AE, Hendricks RL and Khalil MA, et al. Segmental (floating) lumbar spine fusion. Spine. 14:447–450. 1989.
4). Brunet JA and Wiley JJ. Acquired spondylolysis after spinal fusion. J Bone and Joint Surg. 66-B:720–724. 1984.
5). Chen WJ, Lai PL, Niu CC, Chen LH, Fu TS and Wong CB. Surgical treatment of adjacent instability after lumbar spine fusion. Spine. 26:E519–524. 2001.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
6). Etebar S and Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg. 90:163–169. 1999.
7). Fritsch EW, Heisel J and Rupp S. The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments. Spine. 21:626–633. 1996.
8). Frymoyer JW, Hanley E, Howe J, Kuhlmann D and Matteri R. Disc excision and spine fusion in the management of lumbar disc disease. A minimum 10 year follow-up. Spine. 13:1–6. 1978.
9). Frymoyer JW, Hanley E, Howe J, Kuhlmann D and Matteri R. A comparison of radiolographic findings in fusion and nonfusion patients ten or more years following lumbar disc surgery. Spine. 4:435–440. 1979.
10). Guigui P, Lambert P, Lassale B and Deburge A. Long term outcome at adjacent levels of lumbar arthrodesis. Rev Chir Orthop Reparatrice Appar Mot. 83:685–696. 1997.
11). Ha KY and Sung TP. Changes of the adjacent mobile segment after cat spine fixation. J of Korean Orthop Surgery. 32:1808–1816. 1997.
12). Ha KY, Schendel MJ, Lewis JL and Ogilvie JW. Effect of immobilization and configuration on lumbar adjacent segment biomechanics. J Spinal Disord. 6:99–105. 1993.
13). Ha KY, Kim KY, Park SJ and Lee YH. Changes of the adjacent-unfused mobile segment after instrumental lumbar fusion. - More than 5years follow-up-. J Kor Spine Surg. 5:205–214. 1998.
14). Ha KY, Moon MS and Paek SY. Effect of Instumental stabilization and fusion of degenerative lumbar scoliosis on unfused adjacent segment. J Kor Spine Surg. 2:270–278. 1995.
15). Hambly MF, Wiltse LL, Raghavan N, Schneiderman G and Koenig C. The transition zone above a lumbosacral fusion. Spine. 23:1785–1792. 1998.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
16). Harris RI and Wiley JJ. Acquired spondylolysis as a sequel to spine fusion. J Bone and Joint Surg. 45-A:1159–1170. 1963.
17). Kettler A, Wilke HJ, Haid C and Claes L. Effects of specimen length on the monosegmental motion behaviour of the lumbar spine. Spine. 25:543–550. 2000.
18). Kellgren. The epidemiology of chronic rheumatism, Vol 2: Atlas of standard radiographs of arthritis. England: Blackwell Scientific Publications Ltd;1963.
19). Kim SS and Michelsen CB. Revision surgery for failed back surgery syndrome. Spine. 17:957–960. 1992.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
20). Kumar MN, Baklanov A and Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J. 10:314–319. 2001.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
21). Kumar MN, Jacquot F and Hall H. Long-term follow- up of functional outcomes and radiographic changes at adjacent levels following lumbar spine fusion for degenerative disc disease. Eur Spine J. 10:309–313. 2001.
22). Lee CK. Accelerated degeneration of the segment adjacent to a lumbar fusion. Spine. 13:375–7. 1988.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
23). Lee CK and Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine. 9:574–581. 1984.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
24). Lehmann TR, Spratt KF, Tozzi JE, et al. Long-term follow-up of lower lumbar fusion patients. Spine. 12:97–104. 1987.
![crossref](/image/icon/bnr_ref_cross.gif)
![crossref](/image/icon/bnr_ref_cross.gif)
25). Rahm MD and Hall BB. Adjacent-segment degeneration after lumbar fusion with instrumentation: A retrospective study. J Spinal Disord. 9:392–400. 1996.
26). Schlegel JD, Smith JA and Schleusener RL. Lu mbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Spine. 21:970–981. 1996.
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](/upload/SynapseXML/0089jkss/thumb/jkss-9-332f1.gif)
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](/upload/SynapseXML/0089jkss/thumb/jkss-9-332f2.gif)
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](/upload/SynapseXML/0089jkss/thumb/jkss-9-332f3.gif)
Table 1.
Patients Demographics
Table 2.
Radiologic grading of adjacent segment degeneration (prior to 1° surgery).