J Korean Soc Spine Surg.  2015 Sep;22(3):69-74. 10.4184/jkss.2015.22.3.69.

The Impact of Lumbar Lordosis on the Adjacent Segment Disease after Posterior Lumbar Interbody Fusion

• Kim KT
• Suk KS
• Lee SH
• Lee JH
• Kim MH
• Park DH
• Huh DS
• Kim DH

• KMID: 2068923
• DOI: http://doi.org/10.4184/jkss.2015.22.3.69

Abstract

STUDY DESIGN: A retrospective study.
OBJECTIVES
We analyzed the risk factors and relevance of lumbar lordosis on the incidence of adjacent segment disease after posterior lumbar interbody fusion. SUMMARY OF LITERATURE REVIEW: Maintaining lumbar sagittal balance is important for decreasing the incidence of adjacent segment disease after posterior lumbar interbody fusion.
MATERIALS AND METHODS
Among the patients who had undergone posterior lumbar interbody fusion of 1 or 2 levels between August 2001 and October 2008, we analyzed 153 patients who were available for at least three years of follow-up; among the subjects, 115 were males and 38 were females. Mean age among the patients at the time of initial surgery was 60.3 (range, 41-82) and mean followup period was 5.6 years (range, 3-11). The causative diseases were spinal stenosis in 78 cases, degenerative spondylolisthesis in 51 cases, isthmic spondylolisthesis in 23 cases, and degenerative disc disease in 1 case. At last follow-up, there were 52 cases (33.9%) of adjacent segment disease. Among them were found 21 cases (40.4%) of disc degeneration, 17 cases (32.7%) of instability, and 14 cases (26.9%) of simultaneous disc degeneration and instability. A total of 10 patients (6.5%) underwent a revision operation, and the mean period from initial to revision operation was 5.5 years (range, 3.1-10.3). We analyzed the correlation between risk factors of adjacent segment disease and the incidence of the disease depending on the gap between lumbar lordosis and pelvic incidence, and compared the clinical results of the 2 groups using modified Whitecloud classification.
RESULTS
The incidence of adjacent segment disease was not statistically significant for patient age, sex, BMD, degree of obesity, causative disease, and the level of previous surgery. However, the incidence of adjacent segment disease was statistically higher in patients who had more than 9 degrees gap between lumbar lordosis and pelvic incidence (p=0.013). In our analysis of clinical results, 63.5% of the group of patients who developed adjacent segment disease and 80.2% of the group without adjacent segment disease had good or satisfactory results (p=0.031).
CONCLUSIONS
Maintaining lumbar sagittal balance is important for decreasing the incidence of adjacent segment disease after posterior lumbar interbody fusion, and close observation is needed in patients with 9 or more degrees gap between lumbar lordosis and pelvic incidence.

Keyword

Adjacent segment; Lumbar fusion; Risk factor running

MeSH Terms

Animals
Classification
Female
Follow-Up Studies
Humans
Incidence
Intervertebral Disc Degeneration
Lordosis*
Male
Obesity
Retrospective Studies
Risk Factors
Spinal Stenosis
Spondylolisthesis

Figure

• 

  Fig. 1. (A) Initial diagnosis was degenerative spondylolisthesis L3-4-5. (B) PLIF was done L3-4-5. In whole spine standing radiograph at postoperative 3 months, lumbar lordosis (LL) was 40.8°, pelvic incidence (PI) was 52.2° (discrepancy=11.4°). (C) At postoperative 3.9 years, ASD was developed at L2-3. (D) PLIF extension was done.

Reference

1. Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976). 2004; 29:1938–44.

2. Whitecloud TS, Davis JM, Olive PM. Operative treatment of the degenerated segment adjacent to a lumbar fusion. Spine (Phila Pa 1976). 1994; 19:531–6.

3. Phillips FM, Carlson GD, Bohlman HH, et al. Results of surgery for spinal stenosis adjacent to previous lumbar fusion. J Spinal Disord. 2000; 13:432–7.

4. Hue KY, Zucherman J, White A, et al. Deterioration of motion segments adjacent to lumbar fusions. Annual meeting of North American Spine Society, Colorado Springs, Colorado. 1998.

5. Schlegel JD, Smith JA, Schleusener RL. Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Spine (Phila Pa 1976). 1996; 21:970–81.

6. Chen WJ, Lai PL, Niu CC, Chen LH, Fu TS, Wong CB. Surgical treatment of adjacent instability after lumbar spine fusion. Spine (Phila Pa 1976). 2001; 26:519–24.

7. Rahm MD, Hall BB. Adjacent-segment degeneration after lumbar fusion with instrumentation: a retrospective study. J Spinal Disord. 1996; 9:392–400.

8. Kumar MN, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J. 2001; 10:314–9.

9. Legaye J, Duval-Beaupè re G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. Eur Spine J. 1998; 7:99–103.

10. Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane consid-erations and the pelvis in the adult patient. Spine (Phila Pa 1976). 2009; 34:1828–33.

11. Ghiselli G, Wang JC, Hsu WK, et al. L5–S1 segment survi-vorship and clinical outcome analysis after L4-L5 isolated fusion. Spine (Phila Pa 1976). 2003; 28:1275–80.

12. Dupuis PR, Yong-Hing K, Cassidy JD, Kirkaldy-Willis WH. Radiologic diagnosis of degenerative lumbar spinal instability. Spine (Phila Pa 1976). 1985; 10:262–76.

13. Lehmann TR, Spratt KF, Tozzi JE. Longterm followup of lower lumbar fusion patients. Spine (Phila Pa 1976). 1987; 12:97–104.

14. Hilibrand AS, Robbins M. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine J. 2004; 4(Suppl):190–4.

15. Gillet P. The fate of the adjacent motion segments after lumbar fusion. J Spinal Disord Tech. 2003; 16:338–45.

16. Schlegel JD, Smith JA, Schleusener RL. Lumbar motion segment pathology adjacent to thoracolumbar, lumbar and lumbosacral fusion. Spine (Phila Pa 1976). 1996; 21:970–81.

17. Kumar MN, Jacquot F, Hall H. Longterm follow up of functional outcomes and radiographic changes at adjacent levels following lumbar spine fusion for degenerative disc disease. Eur Spine J. 2001; 10:309–13.

18. Grouw AV, Nadel CI, Weierman RJ, Lowell HA. Longterm followup of patients with idiopathic scoliosis treated surgically. Clin Orthop Relat Res. 1976; 117:197–201.

19. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991; 73:802–8.

20. Ha KY, Kim YH, Kang KS. Surgery for Adjacent Segment Changes after Lumbosacral Fusion. J Korean Soc Spine Surg. 2002; 9:332–40.