Outcomes in Adult Scoliosis Patients Who Undergo Spinal Fusion Stopping at L5 Compared with Extension to the Sacrum

Abstract

Study Design Systematic review. Study Rationale Adult scoliosis is a common disorder that is associated with significantly higher pain, functional impairment, and effect on quality of life than those without scoliosis. Surgical spinal fusion has led to quantifiable improvement in patient's quality of life. However, for patients undergoing long lumbar fusion, the decision to stop the fusion at L5 or to extend to S1, particularly if the L5–S1 disc is healthy, remains controversial. Objective The aim of the study is to evaluate if fusion stopping at L5 increases the comparative rates of revision, correction loss, and/or poor functional outcomes compared with extension to the sacrum in adult scoliosis patients who require spinal fusion surgery. Materials and Methods A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Database and bibliographies of key articles that evaluated adult scoliosis patients who required spinal fusion surgery and compared outcomes for fusions to the sacrum versus stopping at L5. Articles were included on the basis of predetermined criteria and were appraised using a predefined quality-rating scheme. Results From 111 citations, 26 articles underwent full-text review, and 3 retrospective cohort studies met all inclusion and exclusion criteria. Revision rates in subjects who underwent spinal fusion to L5 (20.8–23.5%) were lower in two studies compared with those with fusion extending to the sacrum (19.0–58.3%). Studies that assessed deformity correction used different measures, making comparison across studies difficult. No significant differences were found in patient-reported functional outcomes across two studies that used different measures. Conclusion The limited data available suggest that differences in revision rates did not consistently reach statistical significance across studies that compared spinal fusion to L5 versus extension to sacrum in adult scoliosis patients.

Comparison of long fusion terminating at L5 versus the sacrum in treating adult spinal deformity: a meta-analysis

“…There was also no significant difference in revision rate between both groups. The result was consistent with a previous systematic review of three studies on this topic [40]. In L group, extension of fusion to the sacrum was the most common revision procedure [15,18].…”

The preoperative predictors for subsequent degeneration in L5-S1 disc after long fusion arthrodesis terminating at L5 in patients with adult scoliosis: focus on spinopelvic parameters

“…When outcomes of conservative treatment are poor, surgical treatment is a better choice to relieve the symptoms. Nowadays, the surgical treatment of adult scoliosis is widely concerned by spinal surgeons [ 2 – 4 , 6 – 9 ]. Sardar et al [ 9 ] published a retrospective study to contrast the outcomes of long fusion arthrodesis terminating at L5 and extension to the sacrum, showing no statistical significance in both groups; the same result was found in the study of Edwards et al [ 4 ].…”

“…Nowadays, the surgical treatment of adult scoliosis is widely concerned by spinal surgeons [ 2 – 4 , 6 – 9 ]. Sardar et al [ 9 ] published a retrospective study to contrast the outcomes of long fusion arthrodesis terminating at L5 and extension to the sacrum, showing no statistical significance in both groups; the same result was found in the study of Edwards et al [ 4 ]. Nevertheless, choosing L5 or S1 as the distal fixed vertebrae was still controversial because of different incidence of complications [ 4 , 17 – 19 ].…”

“…Due to the complications, patients after long fusion arthrodesis terminating at L5 required revision surgery whose distal fixed vertebrae should extend to S1 or even to the iliac bone [ 2 , 3 , 6 ]. Previous studies have paid attention to complications, risk factors, radiographic parameters, surgical outcomes, and revision surgery, which are caused by subsequent degeneration in L5-S1 disc [ 2 , 4 , 6 – 9 ]. Nevertheless, just a few studies discussed the preoperative predictors of subsequent degeneration in L5-S1 disc after the long fusion arthrodesis terminating at L5 in patients with adult scoliosis, although it was beneficial for surgical strategy.…”

L5-S1 Survival After Interbody Fusion by Lateral Approach Until L5 in Degenerative Disease

“…1 When analyzing arthrodesis for the treatment of adult deformities of degenerative diseases of multiple levels of the lumbar spine, there is still no firm answer to the question about which distal level should be used for instrumentation, L5 or the sacrum, and this question is the topic of studies by various authors. [2][3][4][5][6][7][8][9][10][11] In the literature, primary arthrodesis to the sacrum is recommended in cases of advanced L5-S1 disc degeneration, significant lumbosacral obliquity, spondylolysis, or spondylolisthesis of L5, canal/foraminal stenosis in L5-S1, or prior decompressions at this level. Otherwise, using L5 as the distal level may be considered.…”