J Korean Orthop Assoc.  2009 Feb;44(1):109-117. 10.4055/jkoa.2009.44.1.109.

Proximal Adjacent Segment Disease following Posterior Instrumentation and Fusion for Degenerative Lumbar Scoliosis

• Cho KJ
• Park SL
• Kim MG
• Yoon YH
• Lee JS
• Suk SI

• KMID: 2186385
• DOI: http://doi.org/10.4055/jkoa.2009.44.1.109

Abstract

PURPOSE
Adjacent segment disease (ASD) is major complication following spinal instrumentation and fusion. The purpose of the current study was to determine the prevalence and risk factors of proximal ASD following posterior instrumentation and fusion for degenerative lumbar scoliosis.
MATERIALS AND METHODS
Seventy-two patients (mean age 64.8 years) who had undergone decompression and fusion with pedicle screw instrumentation were evaluated. The average follow-up was 4.7 years. Twenty-five patients had additional interbody fusion at the lower lumbar spine. The average number of levels fused was 5.1 segments (range 1-9). The upper instrumented vertebrae ranged from T9 to L4. The lower instrumented vertebrae were L5 and S1.
RESULTS
Proximal ASD developed in 17 (24%) of 72 patients, including compression fractures (n=6), junctional kyphosis (n=5), spinal stenosis (n=4), and symptomatic disc collapse (n=2). The preoperative scoliotic angle, lumbar lordosis, thoracic kyphosis, and coronal and sagittal C7 plumb were not associated with the development of proximal ASD. There was a close correlation between the level of the upper instrumented vertebrae and the development of ASD (p=0.001). When fusion did not extend beyond the lumbar vertebra, ASD occurred in 15 (38.5%) of 39 patients. In contrast, when fusion extended up to the thoracic vertebrae, ASD occurred in 2 (6.1%) of 33 patients. The improvement in the Oswestry score was superior to the group without ASD (p=0.001).
CONCLUSION
The prevalence of symptomatic ASD at the proximal segment was 24% after posterior instrumentation and fusion for degenerative lumbar scoliosis. The cephalad extent of fusion was the most significant risk factor for the development of proximal ASD.

Keyword

Degenerative lumbar scoliosis; Adjacent segment disease; Extent of fusion

MeSH Terms

Animals
Decompression
Follow-Up Studies
Fractures, Compression
Humans
Kyphosis
Lordosis
Prevalence
Risk Factors
Scoliosis
Spinal Stenosis
Spine
Thoracic Vertebrae

Figure

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  Fig. 1 Distribution of upper instrumented vertebra.

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  Fig. 2 Preoperative radiographs of the lumbar spine. A 58-years-old woman with spinal stenosis and degenerative lumbar scoliosis. (A) Anteroposterior radiograph showing degenerative lumbar scoliosis. (B) Lateral radiograph showing a disc space narrowing at lumbar spine.

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  Fig. 3 (A, B) Immediate postoperative anteroposterior and lateral radiographs showing posterior fusion to L2 from S1.

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  Fig. 4 (A) Two years after surgery, the patient complained of claudication and radicular pain to both legs with junctional kyphosis at L1-2 on the radiographs. (B, C) MRI showed spinal stenosis at L1-2.

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  Fig. 5 (A, B) We performed revision surgery extending fusion to T10.

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