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

Study Design. Review of the literature. Objectives. Review the definition, etiology, incidence, and risk factors associated with as well as potential treatment options. Summary of Background Data. The development of pathology at the mobile segment next to a lumbar or lumbosacral spinal fusion has been termed adjacent segment disease. Initially reported to occur rarely, it is now considered a potential late complication of spinal fusion that can necessitate further surgical intervention and adversely affect outcomes. Methods. MEDLINE literature search. Results. The most common abnormal finding at the adjacent segment is disc degeneration. Biomechanical changes consisting of increased intradiscal pressure, increased facet loading, and increased mobility occur after fusion and have been implicated in causing adjacent segment disease. Progressive spinal degeneration with age is also thought to be a major contributor. From a radiographic standpoint, reported incidence during average postoperative follow-up observation ranging from 36 to 369 months varies substantially from 5.2 to 100%. Incidence of symptomatic adjacent segment disease is lower, however, ranging from 5.2 to 18.5% during 44.8 to 164 months of follow-up observation. The rate of symptomatic adjacent segment disease is higher in patients with transpedicular instrumentation (12.2–18.5%) compared with patients fused with other forms of instrumentation or with no instrumentation (5.2–5.6%). Potential risk factors include instrumentation, fusion length, sagittal malalignment, facet injury, age, and pre-existing degenerative changes. Conclusion. Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common but does not correlate with functional outcomes. Potentially modifiable risk factors for the development of adjacent segment disease include fusion without instrumentation, protecting the facet joint of the adjacent segment during placement of pedicle screws,fusion length, and sagittal balance. Surgical management, when indicated, consists of decompression of neural elements and extension of fusion. Outcomes after surgery, however, are modest.

[1]  Matthew J. Crawford,et al.  Kinematic Evaluation of Lumbar Fusion Techniques , 1996, Spine.

[2]  J. Lotz,et al.  Compression-induced degeneration of the intervertebral disc: an in vivo mouse model and finite-element study. , 1998, Spine.

[3]  A. Brodsky.  Post-laminectomy and post-fusion stenosis of the lumbar spine. , 1976, Clinical orthopaedics and related research.

[4]  L H Chen,et al.  Surgical Treatment of Adjacent Instability After Lumbar Spine Fusion , 2001, Spine.

[5]  N. Langrana,et al.  Lumbosacral spinal fusion. A biomechanical study. , 1984, Spine.

[6]  L. Unander-Scharin.  A case of spondylolisthesis lumbalis acquisita. , 1950, Acta orthopaedica Scandinavica.

[7]  K. Yamamoto,et al.  Adjacent-segment morbidity after Graf ligamentoplasty compared with posterolateral lumbar fusion. , 2001, Journal of neurosurgery.

[8]  J. Schlegel,et al.  Lumbar Motion Segment Pathology Adjacent to Thoracolumbar, Lumbar, and Lumbosacral Fusions , 1996, Spine.

[9]  S Etebar,et al.  Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. , 1999, Journal of neurosurgery.

[10]  B. Strömqvist,et al.  The Spondylolytic Vertebra and Its Adjacent Segment: Mobility Measured Before and After Posterolateral Fusion , 1997, Spine.

[11]  T. Taylor,et al.  Effects of spinal fusion on the proteoglycans of the canine interverebral disc , 1985, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[12]  J W Frymoyer,et al.  A Comparison of Radiographic Findings in Fusion and Nonfusion Patients Ten or More Years Following Lumbar Disc Surgery , 1979, Spine.

[13]  T. Zdeblick.  A prospective, randomized study of lumbar fusion. Preliminary results. , 1993, Spine.

[14]  J. Lewis,et al.  Effect of immobilization and configuration on lumbar adjacent-segment biomechanics. , 1993, Journal of spinal disorders.

[15]  L. Lenke,et al.  Minimum 5-year results of degenerative spondylolisthesis treated with decompression and instrumented posterior fusion. , 1999, Spine.

[16]  Methodology of Guideline Development. , 2002, Neurosurgery.

[17]  I. Stokes,et al.  Assessment of Patients With Low-Back Pain by Biplanar Radiographic Measurement of Intervertebral Motion , 1981, Spine.

[18]  T. Whitecloud,et al.  Operative treatment of the degenerated segment adjacent to a lumbar fusion. , 1994, Spine.

[19]  J. Leong,et al.  Long‐Term Results of Lumbar Intervertebral Disc Prolapse , 1983, Spine.

[20]  R. Fraser,et al.  Magnetic Resonance Imaging Assessment of Disc Degeneration 10 Years After Anterior Lumbar Interbody Fusion , 1995, Spine.

[21]  S. L. Griffith,et al.  Four-Year Follow-up Results of Lumbar Spine Arthrodesis Using the Bagby and Kuslich Lumbar Fusion Cage , 2000, Spine.

[22]  G. Carlson,et al.  Results of surgery for spinal stenosis adjacent to previous lumbar fusion. , 2000, Journal of spinal disorders.

[23]  Y. Shimada,et al.  Outcome of One-Level Posterior Lumbar Interbody Fusion for Spondylolisthesis and Postoperative Intervertebral Disc Degeneration Adjacent to the Fusion , 2000, Spine.

[24]  K. Herrlin,et al.  Posterolateral lumbar fusion. Outcome of 71 consecutive operations after 4 (2-7) years. , 1994, Acta orthopaedica Scandinavica.

[25]  B. Cunningham,et al.  The Effect of Spinal Destabilization and Instrumentation on Lumbar Intradiscal Pressure: An In Vitro Biomechanical Analysis , 1997, Spine.

[26]  M. Zindrick,et al.  A Comparison of Single‐Level Fusions With and Without Hardware , 1991, Spine.

[27]  K. Kumano,et al.  Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. , 1995, Journal of spinal disorders.

[28]  John H. Evans,et al.  Effects of Short Anterior Lumbar Interbody Fusion on Biomechanics of Neighboring Unfused Segments , 1996, Spine.

[29]  C. Anderson.  Spondyloschisis following spine fusion. , 1956, The Journal of bone and joint surgery. American volume.

[30]  M. Schendel,et al.  Magnetic Resonance Imaging and Biological Changes in Injured Intervertebral Discs Under Normal and Increased Mechanical Demands , 1996, Spine.

[31]  L. Wiltse,et al.  The Transition Zone Above a Lumbosacral Fusion , 1998, Spine.

[32]  H. Matsui,et al.  Minimum 10-year follow-up study of anterior lumbar interbody fusion for isthmic spondylolisthesis. , 2001, Journal of spinal disorders.

[33]  P. Guigui,et al.  [Long-term outcome at adjacent levels of lumbar arthrodesis]. , 1997, Revue de chirurgie orthopedique et reparatrice de l'appareil moteur.

[34]  F. T. Wetzel,et al.  Intervertebral disc degeneration adjacent to a lumbar fusion. An experimental rabbit model. , 2002, The Journal of bone and joint surgery. British volume.

[35]  A. Patwardhan,et al.  The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments. , 2000, Spine.

[36]  J L Lewis,et al.  The effects of immobilization of long segments of the spine on the adjacent and distal facet force and lumbosacral motion. , 1993, Spine.

[37]  S Nakai,et al.  Long-term follow-up study of posterior lumbar interbody fusion. , 1999, Journal of spinal disorders.

[38]  D. Schlenzka,et al.  Disc degeneration in young patients with isthmic spondylolisthesis treated operatively or conservatively: A long-term follow-up , 2005, European Spine Journal.

[39]  V K Goel,et al.  Effect of Disc Degeneration at One Level on the Adjacent Level in Axial Mode , 1991, Spine.

[40]  O. Böstman,et al.  Posterolateral lumbosacral fusion with transpedicular fixation: 63 consecutive cases followed for 4 (2-6) years. , 1996, Acta orthopaedica Scandinavica.

[41]  W. Lo,et al.  Stress analysis of the disc adjacent to interbody fusion in lumbar spine. , 2001, Medical engineering & physics.

[42]  S. L. Griffith,et al.  Intradiscal Pressure Measurements Above an Instrumented Fusion: A Cadaveric Study , 1995, Spine.

[43]  H. Stockdale,et al.  Some Experimental Observations of the Influence of a Single Lumbar Floating Fusion on the Remaining Lumbar Spine , 1981, Spine.

[44]  J. Lewis,et al.  Comparison of In Vivo and In Vitro Adjacent Segment Motion After Lumbar Fusion , 1994, Spine.

[45]  M. Rahm,et al.  Adjacent-segment degeneration after lumbar fusion with instrumentation: a retrospective study. , 1996, Journal of spinal disorders.

[46]  J. Weinstein,et al.  Long-term Follow-up of Lower Lumbar Fusion Patients , 1987, Spine.

[47]  C. Niu,et al.  Survivorship Analysis of DKS Instrumentation in the Treatment of Spondylolisthesis , 1997, Clinical orthopaedics and related research.

[48]  Chen-Sheng Chen,et al.  A biomechanical comparison of posterolateral fusion and posterior fusion in the lumbar spine. , 2002, Journal of spinal disorders & techniques.

[49]  CASEY K. LEE,et al.  Accelerated Degeneration of the Segment Adjacent to a Lumbar Fusion , 1988, Spine.

[50]  T. Taylor,et al.  The response of the canine intervertebral disc to immobilization produced by spinal arthrodesis is dependent on constitutional factors , 1987, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[51]  J. V. van Horn,et al.  The development of discopathy in lumbar discs adjacent to a lumbar anterior interbody spondylodesis. A retrospective matched-pair study with a postoperative follow-up of 16 years. , 1992, Acta orthopaedica Belgica.

[52]  C. Wimmer,et al.  AP-translation in the proximal disc adjacent to lumbar spine fusion. A retrospective comparison of mono- and polysegmental fusion in 120 patients. , 1997, Acta orthopaedica Scandinavica.

[53]  L. Wiltse,et al.  Comparative study of the incidence and severity of degenerative change in the transition zones after instrumented versus noninstrumented fusions of the lumbar spine. , 1999, Journal of spinal disorders.