Analysis of Risk Factors and Surgical Results of Lumbar Adjacent Segment Disease

Whoan Jeang Kim; Jong Won Kang; Byoung Sub Kam; Sung Il Kang; Won Cho Kwon; Kun Young Park; Jae Guk Park; Hwan Il Sung; Won Sik Choy

doi:10.4184/JKSS.2010.17.2.74

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Kim, Kang, Kam, Kang, Kwon, Park, Park, Sung, and Choy: Analysis of Risk Factors and Surgical Results of Lumbar Adjacent Segment Disease

Original Research

J Korean Soc Spine Surg 2010;17(2):74-81.

Published online: 18 June 2010

DOI: https://doi.org/10.4184/JKSS.2010.17.2.74

Analysis of Risk Factors and Surgical Results of Lumbar Adjacent Segment Disease

Whoan Jeang Kim, M.D., Jong Won Kang, M.D., Byoung Sub Kam, M.D., Sung Il Kang, M.D., Won Cho Kwon, M.D., Kun Young Park, M.D.^∗, Jae Guk Park, M.D.^†, Hwan Il Sung, M.D.^‡, Won Sik Choy, M.D.

Department of Orthopaedic Surgery

^∗Eulji University School of Medicine, Daejeon Veterans Hospital

^{^†}Hongseong Medical Center

^{^‡}Gimcheon Jeil Hospital

Corresponding author: Jong Won Kang, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, 1306, Dunsan-dong, Seo-gu, Daejon 302-799, Korea TEL: 82-42-611-3279, FAX : 82-42-259-1289 E-mail: jwkang@eulji.ac.kr

Received 1 December 200911 April 2010 Accepted 14 May 2010

“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

This is a retrospective study.

Objectives

We analyzed the risk factors and the surgical results for adjacent segment disease after lumbar fusion.

Summary of Literature Review

Many studies have been performed about the risk factors for adjacent segment disease, but the findings are still controversial.

Materials and Methods

This study was carried out on 35 (13 men, 22 women) of 50 patients who underwent lumbar fusion due to adjacent segment disease with a minimum of 2 year follow-up period from July 1999 to July 2006. The differences of the interval to revision (IR) were statistically analyzed by the examining preexisting degenerative change in the adjacent segments on MRI, the number of fused segments, the lumbar lordosis and the sagittal balance. The surgical outcomes of reoperation were assessed by Brodsky's criteria.

Results

Junctional stenosis as adjacent segment disease was seen in 21 cases (60%) and instability was seen in 14 cases (40%), including 2 iatrogenic flat backs and 2 cases of lumbar degenerative kyphosis. The average IR was 93 months for the cases that had less than 2 segment fusion (20 cases) and 62 months in those with more than 3 segment fusion (15 cases). As for lumbar lordosis, 25 cases (71%) had a normal range of angle as well as 101 months until the IR and 10 cases (29%) had an abnormal range of angle as well as 64 months until IR. Six cases were beyond the normal range of sagittal balance (17%) and their average IR value was 59 months. Otherwise, the cases with a normal range of sagittal balance had 109 months for the IR. The clinical outcome was excellent in 6 cases (17%) and good in 15 cases (43%).

Conclusion

To decrease the adjacent segment disease, we should seriously consider the extent of lumbar fusion and we should restore the angle in lumbar lordosis to the physiological range and the sagittal balance during the initial operation.

Keywords: Adjacent segment, Lumbar fusion, Risk factor

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Fig. 1.

Radiologic measurement of sagittal balance.

Fig. 2.

A 66-year-old woman with 2 segments fusion (A) and a 69-year-old man with 3 segments fusion (B) within normal range of lumbar curvature had a reoperation after several years. But, a 61-year-old woman underwent 2 segments fusion with abnormal range of lumbar curvature had earlier reoperation than previous two patients (C). All three patients had revision surgery due to junctional stenosis. LL: lumbar lordosis

Fig. 3.

A 65-year-old woman suffered from stenosis L3-4-5 and spondylolisthesis L3 on L4 (A) was treated with posterior decompression and posterior instrumentation from L3 to L5 (B). Several years later the patient suffered from pain due to junctional stenosis at L3-4, loosening of the most proximal screws and iatrogenic flat back (C) . We treated with implant removal, pedicle subtraction osteotomy(PSO) at L3 vertebral body and posterolateral fusion from T11 to S1 (D). The figure (E) shows follow-up radiograph after several years. SVA: sagittal vertical axis, LL: lumbar lordosis

Table 1.

Pfirmann classification of disc degeneration

Grade	Structure	Distinction of nucleus and annulus	Signal intensity	Height of intervertebral disc
I	Homogenous, bright white	Clear	Hyperintense, isointense to cerebrospinal fluid	Normal
II	Inhomogenous with or without horizontal bands	Clear	Hyperintense, isointense to cerebrospinal fluid	Normal
III	Inhomogenous, gray	Unclear	Intermediate	Normal to slightly decreased
IV	Inhomogenous, gray to black	Lost	Intermediate to hypointense	Normal to moderately decreased
V	Inhomogenous, black	Lost	Hypointense	Collapsed disc space

Table 2.

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

Table 3.

Lumbar lordosis

	Pre-op(°)		Post-op(°)	IR(months)^∗
Lumbar lordosis (cases)	Normal(25)	37.5.±4.9	42.0±5.1	101(85-125)
Lumbar lordosis (cases)	Abnormal(10)	15.0±3.7	24.5±3.1	64(43-90)

Pre-op: pre-operative, Post-op: post-operative.

Reference value: 25~67°

IR(months)∗: mean duration of interval to revision(minimum-maximum), p=0.01

Table 4.

Sagittal balance

	Pre-op(SVA, cm)		Post-op(SVA, cm)	IR(months)^∗
Sagittal balance (cases)	Normal(29cases)	+3.4±1.2	+2.9±2.2	109(83-125)
Sagittal balance (cases)	Abnormal(6cases)	+5.6±3.2	+4.7±2.5	59(43-80)

IR(months) : mean duration of interval to revision(minimum-maximum)

Reference value: -5.7~5.2cm

SVA: sagittal vertical axis, p=0.007

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