J Korean Soc Spine Surg.  2010 Jun;17(2):74-81. 10.4184/jkss.2010.17.2.74.

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

• Kim WJ
• Kang JW
• Kam BS
• Kang SI
• Kwon WC
• Park KY
• Park JG
• Sung HI
• Choy WS

• KMID: 1459271
• DOI: http://doi.org/10.4184/jkss.2010.17.2.74

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.

Keyword

Adjacent segment; Lumbar fusion; Risk factor

MeSH Terms

Animals
Constriction, Pathologic
Ethylenes
Follow-Up Studies
Humans
Kyphosis
Lordosis
Male
Reference Values
Reoperation
Retrospective Studies
Risk Factors
Ethylenes

Figure

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  Fig. 1. Radiologic measurement of sagittal balance.

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  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

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