Clin Orthop Surg.  2024 Feb;16(1):86-94. 10.4055/cios23183.

Fusion Length Requiring Spinopelvic Fixation in Lumbosacral Fusion with Anterior Column Support at L5–S1: Assessment of Fusion Status Using Computed Tomography

• Park SC
• Park S
• Lee DH
• Seo J
• Yang JH
• Kang MS
• Nam Y
• Suh SW

• KMID: 2550832
• DOI: http://doi.org/10.4055/cios23183

Abstract

Background
The lumbosacral (LS) junction has a higher nonunion rate than other lumbar segments, especially in long-level fusion. Nonunion at L5–S1 would result in low back pain, spinal imbalance, and poor surgical outcomes. Although anterior column support at L5–S1 has been recommended to prevent nonunion in long-level LS fusion, fusion length requiring additional spinopelvic fixation (SPF) in LS fusion with anterior column support at L5–S1 has not been evaluated thoroughly. This study aimed to determine the number of fused levels requiring SPF in LS fusion with anterior column support at L5–S1 by assessing the interbody fusion status using computed tomography (CT) depending on the fusion length.
Methods
Patients who underwent instrumented LS fusion with L5–S1 interbody fusion without additional augmentation and CT > 1 year postoperatively were included. The fusion rates were assessed based on the number of fused segments. Patients were divided into two groups depending on the L5–S1 interbody fusion status: those with union vs. those with nonunion. Binary logistic regression analyses were performed to identify risk factors for LS junctional nonunion.
Results
Fusion rates of L5–S1 interbody fusion were 94.9%, 90.3%, 80.0%, 50.0%, 52.6%, and 43.5% for fusion of 1, 2, 3, 4, 5, and ≥ 6 levels, respectively. The number of spinal levels fused ≥ 4 (p < 0.001), low preoperative bone mineral density (BMD; adjusted odds ratio [aOR], 0.667; p = 0.035), and postoperative pelvic incidence (PI) – lumbar lordosis (LL) mismatch (aOR, 1.034; p = 0.040) were identified as significant risk factors for nonunion of L5–S1 interbody fusion according to the multivariate logistic regression analysis.
Conclusions
Exhibiting ≥ 4 fused spinal levels, low preoperative BMD, and large postoperative PI–LL mismatch were identified as independent risk factors for nonunion of anterior column support at L5–S1 in LS fusion without additional fixation. Therefore, SPF should be considered in LS fusion extending to or above L2 to prevent LS junctional nonunion.

Keyword

Lumbosacral region; Pseudarthrosis; Spinal fusion; Spinopelvic fixation