Adjacent Segment Disease after Lumbar or Lumbosacral Fusion: Review of the Literature

Park, Paul; Garton, Hugh; Gala, Vishal C.; Hoff, Julian T.; McGillicuddy, John E.

doi:10.1097/01.brs.0000137069.88904.03

Cited by 1,104 publications

(914 citation statements)

References 55 publications

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“…Adjacent segment degeneration is a common long-term sequela or complication of spinal fusion surgery. The exact aetiology is uncertain but alterations in facet loading, hypermobility, and increased intradiscal pressure at the segments adjacent to fusion mass is believed to play a key role [15,21,35,44,51,60]. Superior segment facet violation or laminectomy has recently shown in vitro to destabilize the adjacent level in transpedicular fixation [9].…”

Section: Discussionmentioning

confidence: 99%

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

et al. 2009

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Delayed complications following lumbar spine fusion may occur amongst which is adjacent segment degeneration (ASD). Although interspinous implants have been successfully used in spinal stenosis to authors' knowledge such implants have not been previously used to reduce ASD in instrumented lumbar fusion. This prospective controlled study was designed to investigate if the implantation of an interspinous implant cephalad to short lumbar and lumbosacral instrumented fusion could eliminate the incidence of ASD and subsequently the related reoperation rate. Groups W and C enrolled initially each 25 consecutive selected patients. Group W included patients, who received the Wallis interspinous implant in the unfused vertebral segment cephalad to instrumentation and the group C selected age-, diagnosis-, level-, and instrumentationmatched to W group patients without interspinous implant (controls). The inclusion criterion for Wallis implantation was UCLA arthritic grade \II, while the exclusion criteria were previous lumbar surgery, severe osteoporosis or degeneration[UCLA grade II in the adjacent two segments cephalad to instrumentation. All patients suffered from symptomatic spinal stenosis and underwent decompression and 2-4 levels stabilization with rigid pedicle screw fixation and posterolateral fusion by a single surgeon. Lumbar lordosis, disc height (DH), segmental range of motion (ROM), and percent olisthesis in the adjacent two cephalad to instrumentation segments were measured preoperatively, and postoperatively until the final evaluation. VAS, SF-36, and Oswestry Disability Index (ODI) were used. One patient of group W developed pseudarthrosis: two patients of group C deep infection and one patient of group C ASD in the segment below instrumentation and were excluded from the final evaluation. Thus, 24 patients of group W and 21 in group C aged 65? 13 and 64? 11 years, respectively were included in the final analysis. The follow-up averaged 60 ± 6 months. The instrumented levels averaged 2.5 ? 1 vertebra for both groups. All 45 spines showed radiological fusion 8-12 months postoperatively. Lumbar lordosis did not change postoperatively. Postoperatively at the first cephalad adjacent segment: DH increased in the group W (P = 0.042); ROM significantly increased only in group C (ANOVA, P \ 0.02); olisthesis decreased both in flexion (P = 0.0024) and extension (P = 0.012) in group W. The degeneration or deterioration of already existed ASD in the two cephalad segments was shown in 1 (4.1%) and 6 (28.6%) spines in W and C groups, respectively. Physical function (SF-36) and ODI improved postoperatively (P \ 0.001), but in favour of the patients of group W (P \ 0.05) at the final evaluation. Symptomatic ASD required surgical intervention was in 3 (14%) patients of group C and none in group W. ASD remains a significant problem and accounts for a big portion of revision surgery following instrumented lumbar fusion. In this series, the Wallis interspinous implant changed the natural history of ASD and saved th...

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Section: Discussionmentioning

confidence: 99%

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

et al. 2009

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“…However, discordant findings were found using this treatment, as it did not always result in clinical improvement (7)(8)(9)(10)(11)(12). In fact a high incidence of accelerated disc degeneration at adjacent levels has been reported when patients were treated with a rigid instrumentation system (13)(14)(15).…”

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confidence: 99%

Mid‐term evaluation of the effects of dynamic neutralization system on lumbar intervertebral discs using quantitative molecular MR imaging

Ciavarro

Caiani

Brayda-Bruno

et al. 2011

Magnetic Resonance Imaging

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Purpose: To evaluate the mid-term effects of implant of dynamic neutralization system (Dynesys) on disc tissue in patients with lumbar discopathy, through the quantification of glycosaminoglycans (GAG) concentration, both in treated and adjacent levels, by analysis of delayed gadolinium-enhanced MRI contrast (dGEMRIC) images. Materials and Methods:Ten patients with low back pain underwent the dGEMRIC diagnostic protocol before, 6-months and after 2 years from surgery. Each patient was also evaluated with visual analog (VAS), Oswestry, and Prolo scales both at presurgery and during follow-up. From dGEMRIC images, a DT1 parametric map was obtained for each disc, as quantitative indicator of its GAG concentration, and divided in 13 sectors, which were classified at presurgery as normal or abnormal, based on a 70-ms threshold. Evolution of DT1 was studied during the follow-up.Results: Nine of ten patients completed the follow-up. VAS, Oswestry, and Prolo grades showed an improvement. This was accompanied by a reduction of DT1 in abnormal segments while normal segments showed a pattern of initial worsening at 6 months, followed by an improvement after 2 years. Conclusion:Our study confirmed the improvement in clinical evaluation, and for the first time related this to the changes in discs GAG concentration.

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“…The clinical relevance of ASD is low in the great majority of cases [2,[6][7][8]. Cauda equina syndrome is a very unusual onset of ASD.…”

Section: Discussionmentioning

confidence: 99%

“…Adjacent segment degeneration (ASD) has been defined as a recurrence of symptoms associated with the degeneration at the free segment above a fusion after a symptom-free period [5]. The incidence of (symptomatic) ASD is low, ranging from 5.2 to 18% [2]. We report an unusual case of a patient developing cauda equina syndrome due to recurrent ASD, 8 years after his last posterior instrumented spinal fusion.…”

Section: Introductionmentioning

confidence: 97%

“…This event seems to be determined more by individual characteristics than by fusion, itself [1]. The most common radiographic findings are disc degeneration and hypertrophic facet arthritis, whereas other features, such acquired spondylolisthesis, nucleus pulposus herniation, osteophyte formation, stenosis, and scoliosis, are observed less frequently [2][3][4][5]. Adjacent segment degeneration (ASD) has been defined as a recurrence of symptoms associated with the degeneration at the free segment above a fusion after a symptom-free period [5].…”

Section: Introductionmentioning

confidence: 99%

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Recurrent adjacent segment disease and cauda equina syndrome

et al. 2010

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Purpose A case of cauda equina lesion as a result of recurrent adjacent segment degeneration (ASD) after multiple lumbar fusions is reported. ASD might be a consequence of biomechanical overload or simply a normal degenerative process. The reported clinical relevance of ASD is rather low. We describe an unusual case of cauda equina compression at L1-L2 in a patient who had undergone L2-L4 fusion 8 years previously and 2 decompression-fusion surgeries 16 years before. Materials and methods A 72-year-old man, who had two previous lumbar fusion-decompression procedures, underwent a third lumbar surgery in December 2000 to treat symptomatic spinal canal stenosis associated with L3-L4 pseudoarthrosis. After a symptom-free period of 8 years, the patient experienced low back pain radiating to both legs while standing, associated with saddle sensory disturbances and incontinence. Physical examination ruled out significant motor deficits. Plain radiographs showed solid fusion from L2 to L4, good spinal alignment, and low-grade L1-L2 retrolisthesis. Stainless steel pedicular instrumentation distorted magnetic resonance imaging, preventing adequate spinal canal evaluation. Electromyography demonstrated signs of cauda equina compression (bilateral L3-S2). CT myelography showed a stop at L1-L2, due to a severe spinal canal stenosis. L1-L2 decompression and fusion were performed.Results After an uneventful surgery with no complications, the symptoms abated and incontinence recovered. Conclusions Even if the reported clinical relevance of ASD is very low, fused patients with a constitutional narrow spinal canal are at risk of developing severe neural compression at the level adjacent to the fusion.

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Adjacent Segment Disease after Lumbar or Lumbosacral Fusion: Review of the Literature

Cited by 1,104 publications

References 55 publications

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

Mid‐term evaluation of the effects of dynamic neutralization system on lumbar intervertebral discs using quantitative molecular MR imaging

Recurrent adjacent segment disease and cauda equina syndrome

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