The Relationship between Adjacent Segment Pathology and Facet Joint Violation by Pedicle Screw after Posterior Lumbar Instrumentation Surgery

Abstract

Transpedicular screw instrumentation systems have been increasingly utilized during the fusion of lumbar spine procedures. The superior segment facet joint violation of the pedicle screw is thought to have potential for accelerating symptomatic adjacent-segment pathology (ASP). The purpose of this study was to investigate the relationship between the superior segment facet joint violation by transpedicular screws and the development of ASP. Among all patients who underwent operations involving one- or two-level posterior lumbar arthrodesis at the Chonnam National University Hospital from 1992 to 2012, 87 patients were selected for this study. Fifty-six patients were included in the ASP group, and 31 were included in the non-ASP group. We used lumbar three-dimensional computed tomography (CT) to assess the violation of the superior facet joint by a transpedicular screw. The assessment is presented in scores ranging from zero to two, with zero indicating no violation (type I); one point indicating suspected violation (type II); and two points indicating definitely facet joint violation (type III). Facet violation was reported in 31 patients in the ASP group (n = 56), and in 13 patients in the non-ASP group (n = 31). The types of facet joint violation according to our scoring system were as follows: type I, 59 screws (52.7%); type II, 26 screws (23.2%); and type III, 27 screws (24.1%) in the ASP group; and type I, 43 screws (69.4%), type II, 14 screws (22.6 %); and type III, 5 screws (8.0%) in the non-ASP group. The score of facet joint violation in each patient according to our scoring system were as follows: 0 points, 25 patients (44.6%); 1 point, 8 patients (14.3%); 2 points, 4 patients (7.1%); 3 points, 11 patients (19.7%); 4 points, 8 patients (14.3%) in the ASP group; and 0 points, 18 patients (58.1%); 1 point, 4 patients (12.9%); 2 points, 7 patients (22.6%); 3 points, 2 patients (6.4%); 4 points, 0 patients (0%) in the non-ASP group. The mean scores were 1.4 points in the ASP group and 0.8 points in the non-ASP group (p < 0.05). We conclude that the position of the pedicle screw farther away from the facet joint surface can reduce the degeneration of the superior adjacent segment. Therefore, close attention to the screw position during surgery may reduce the rate of superior adjacent-segment pathologies.

A biomechanical comparison of posterior fixation approaches in lumbar fusion using computed tomography based lumbosacral spine modelling

“…Several studies have shown links between pedicle screw fixation and adjacent segment degeneration (ASD), particularly at the suprajacent level. [30][31][32] These studies also cite facet joint violation as a potential influencing factor, emphasising the importance of facet stabilisation in achieving good clinical outcomes. [30][31][32] The models developed in this FE study simulated traditional pedicle screw trajectory.…”

Predictors of accurate intrapedicular screw placement in single-level lumbar (L4-5) fusion: robot-assisted pedicle screw, traditional pedicle screw, and cortical bone trajectory screw insertion

“…As lumbar fusion has become increasingly used in clinical practice, the incidence of ASD, one of the late complications of this procedure, has also increased gradually [ 7 ]. Superior FJV, as an important risk factor for ASD [ 6 – 8 ], has attracted increasing attention. Since screw malposition may cause serious complications [ 32 ], the safety and accuracy of screw placement are critical.…”

“…ASD has become the major cause of revision surgical procedures after lumbar fusion [ 3 ]. Recent studies have shown that cranial facet joint violation (FJV) is an important risk factor for ASD [ 4 – 8 ]. Injury to the superior facet joints during the placement of pedicle screws was associated with alterations in stability and the load-bearing capability of the adjacent segment [ 9 – 11 ], thus accelerating the degeneration of the joint and ultimately leading to ASD.…”

Comparison of transfacet and pedicle screws in oblique lateral interbody fusion for single-level degenerative lumbar spine diseases: a retrospective propensity score-matched analysis

“…Compared with percutaneous BPS technique, the significant reduction in soft tissue damage is an advantage of percutaneous TFS technique, leading to less functional loss of muscle along with decreased infection rate [ 24 ]. In addition, the most cephalad screw or rod in the construct of percutaneous pedicle screw fixation may mechanically compromise the adjacent facet [ 31 ], which will lead to an increase in the degeneration of adjacent segments [ 32 ]. Differently, no injury of adjacent facets is triggered by transfacet screw fixation due to its entry point and direction and unnecessary rod usage [ 33 ].…”