J Korean Soc Spine Surg.  2008 Sep;15(3):174-182. 10.4184/jkss.2008.15.3.174.

Risk Factors for Adjacent Segment Disease after Posterolateral Lumbar Fusion

• Lee KY
• Sohn SK
• Lee MJ
• Wang L

• KMID: 1747201
• DOI: http://doi.org/10.4184/jkss.2008.15.3.174

Abstract

STUDY DESIGN: This is a retrospective study.
OBJECTIVE
We wanted to analyze the treatment outcome and the risk factors for adjacent segment disease after lumbar fusion. SUMMARY OF LITERATURE REVIEW: Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common after lumbar fusion, but this does not correlate with the functional outcomes.
MATERIALS AND METHODS
We reviewed 544 patients who underwent lumbar fusion at a minimum of 5-year follow-up between March 1993 and August 2006. Risk factors analysis was performed for 48 of 544 patients with adjacent segment disease and who were needed a second operation, and the treatment outcomes were assessed for 46 patients with a minimum 1-year follow-up after the second operation. The average interval to the second operation was 4.5 years, and the average follow-up after the second operation was 34.5 months. The treatment outcome was assessed by using the modified Brodsky criteria and the reoperation rate was assessed in relation to several risk factors.
RESULTS
Excellent and good operative results were obtained in 29 cases (63%) and bony fusion was achieved in 41 cases (89%). Of the risk factors we examined, multi-level fusion, a high grade of initial radiographic degeneration, the loss of physiologic lumbar lordosis and the involvement of degenerative scoliosis were associated with a high reoperation rate, with statistical significance. Age, gender, the initial diagnosis, the upper placement of the proximal screws and the extent to the sacrum were not correlated with the reoperation rate.
CONCLUSION
The treatment outcome was relatively satisfactory; however, the factors influencing the treatment outcome of the second operation still need to be considered. The fusion level, the initial radiographic degeneration, the preservation of lumbar lordosis and the involvement of degenerative scoliosis are considered to be risk factors for the failure of lumbar fusion.

Keyword

Adjacent segment; Lumbar fusion; Treatment outcome; Risk factor

MeSH Terms

Animals
Follow-Up Studies
Humans
Lordosis
Reoperation
Retrospective Studies
Risk Factors
Sacrum
Scoliosis
Treatment Outcome

Figure

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  Fig. 1. Posterolateral fusion with instrumentation at L3-4-5 in a 62 year-old male patient. (A) Postoperative 2 years, plain radiographs show both upper and lower adjacent degenerative changes. (B) Extended posterior decompression and instrumented posterolateral fusion were performed. At the last follow-up, clinical result was good according to the modified Brodsky's criteria.

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  Fig. 2. Posterolateral fusion with instrumentation at L4-5-S1 in a 69 year-old female patient. (A) Postoperative 10 years, plain radiographs show degenerative lumbar scoliotic change about 13 degrees at AP view and adjacent degenerative changes at saggital view. S1 pedicle screw was broken. (B) T2-weight axial MR images show central and lateral recess type stenosis at L2-3 and L3-4. (C) Dynamic radiographs show L3-4 adjacent instability. (D) Metal removal and posterior decompression and instrumented posterolateral fusion were performed. At the last follow-up, clinical result was excellent according to the modified Brodsky's criteria.

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  Fig. 3. A 64 year-old female radiographs. (A) Initial radiographs show multiple osteophytes and disc space narrowing with mild scoliotic change at L3-4-5. (B) Posterior decompression and instrumented posterolateral fusion were performed. Kellgren grade II degeneration and joint space widening were noted at L2-3 on immediate postoperative radiographs. (C) At postoperative 3 years, severe endplate degeneration, disc collapse and advanced scoliosis were noted at L2-3. (D) Computerized axial tomography images show central and lateral recess type stenosis at L1-2-3. (E) Extended posterior decompression and instrumented posterolateral fusion were performed. (F) At the last follow-up, radiographs show bone union and the clinical result was good according to the modified Brodsky's criteria.

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