Transforaminal Endoscopic Surgery for Adjacent Segment Disease After Lumbar Fusion.
Telfeian Albert Edward
OBJECTIVE:The natural history of degenerative disease after instrumented lumbar fusion can result in symptomatic radiculopathy at the adjacent segment. Here we describe our experience with transforaminal endoscopic decompression for the treatment of adjacent segment radiculopathy. METHODS:A technique for the transforaminal endoscopic treatment of lumbar radiculopathy adjacent to instrumented lumbar fusions is presented. Prospectively, we followed a series of 9 consecutive patients operated on with lumbar radiculopathy above (5) or below (4) their instrumented fusion. Preoperative and postoperative clinical data with 2-year follow-up are presented. RESULTS:A consecutive series of 9 patients who underwent transforaminal endoscopic treatment for lumbar radiculopathy adjacent to an instrumented spinal fusion between 2012 and 2014 is presented. Three patients required revision to fusion at 2, 13, and 19 months postoperatively. The mean visual analogue scale score for radicular pain improved from an average pain score before surgery of 8.4 to 1.3 1 year after surgery and the mean visual analogue scale for back pain improved from an average pain score before surgery of 8.0 to 4.7 1 year after surgery (excluding the 1 patient with 2month postoperative failure). CONCLUSIONS:Transforaminal endoscopic surgical access to adjacent level disease pathology may be a unique approach to the treatment of adjacent segment disease because it allows for neural decompression of disc and foraminal pathology without requiring significant destabilizing bone removal. However, the 2-year failure rate presented here is 33%, which indicates that the benefit of this technique may ultimately be temporary.
Adjacent level disease following lumbar spine surgery: A review.
Epstein Nancy E
Surgical neurology international
BACKGROUND:Instrumented lumbar spine surgery is associated with an increased risk of adjacent segment disease (ASD). Multiple studies have explored the various risk factors contributing to ASD that include; fusion length (especially, three or more levels), sagittal malalignment, facet injury, advanced age, and prior cephalad degenerative disease. METHODS:In this selective review of ASD, following predominantly instrumented fusions for lumbar degenerative disease, patients typically underwent open versus minimally invasive surgery (MIS), transforaminal lumbar interbody fusions (TLIFs), posterior lumbar interbody fusions (PLIFs), or rarely posterolateral lumbar instrumented or noninstrumented fusions (posterolateral lumbar fusion). RESULTS:The incidence of ASD, following open or MI lumbar instrumented fusions, ranged up to 30%; notably, the addition of instrumentation in different series did not correlate with improved outcomes. Alternatively, in one series, at 164 postoperative months, noninstrumented lumbar fusions reduced the incidence of ASD to 5.6% versus 18.5% for ASD performed with instrumentation. Of interest, dynamic instrumented/stabilization techniques did not protect patients from ASD. Furthermore, in a series of 513 MIS TLIF, there was a 15.6% incidence of perioperative complications that included; a 5.1% frequency of durotomy and a 2.3% instrumentation failure rate. CONCLUSIONS:The incidence of postoperative ASD (up to 30%) is greater following either open or MIS instrumented lumbar fusions (e.g., TLIF/PLIF), while decompressions with noninstrumented fusions led to a much smaller 5.6% risk of ASD. Other findings included: MIS instrumented fusions contributed to higher perioperative complication rates, and dynamic stabilization did not protect against ASD.
Biomechanical analysis of lateral interbody fusion strategies for adjacent segment degeneration in the lumbar spine.
Metzger Melodie F,Robinson Samuel T,Maldonado Ruben C,Rawlinson Jeremy,Liu John,Acosta Frank L
The spine journal : official journal of the North American Spine Society
BACKGROUND CONTEXT:Surgical treatment of symptomatic adjacent segment disease (ASD) typically involves extension of previous instrumentation to include the newly affected level(s). Disruption of the incision site can present challenges and increases the risk of complication. Lateral-based interbody fusion techniques may provide a viable surgical alternative that avoids these risks. This study is the first to analyze the biomechanical effect of adding a lateral-based construct to an existing fusion. PURPOSE:The study aimed to determine whether a minimally invasive lateral interbody device, with and without supplemental instrumentation, can effectively stabilize the rostral segment adjacent to a two-level fusion when compared with a traditional posterior revision approach. STUDY DESIGN/SETTING:This is a cadaveric biomechanical study of lateral-based interbody strategies as add-on techniques to an existing fusion for the treatment of ASD. METHODS:Twelve lumbosacral specimens were non-destructively loaded in flexion, extension, lateral bending, and torsion. Sequentially, the tested conditions were intact, two-level transforaminal lumbar interbody fusion (TLIF) (L3-L5), followed by lateral lumbar interbody fusion procedures at L2-L3 including interbody alone, a supplemental lateral plate, a supplemental spinous process plate, and then either cortical screw or pedicle screw fixation. A three-level TLIF was the final instrumented condition. In all conditions, three-dimensional kinematics were tracked and range of motion (ROM) was calculated for comparisons. Institutional funds (<$50,000) in support of this work were provided by Medtronic Spine. RESULTS:The addition of a lateral interbody device superadjacent to a two-level fusion significantly reduced motion in flexion, extension, and lateral bending (p<.05). Supplementing with a lateral plate further reduced ROM during lateral bending and torsion, whereas a spinous process plate further reduced ROM during flexion and extension. The addition of posterior cortical screws provided the most stable lateral lumbar interbody fusion construct, demonstrating ROM comparable with a traditional three-level TLIF. CONCLUSIONS:The data presented suggest that a lateral-based interbody fusion supplemented with additional minimally invasive instrumentation may provide comparable stability with a traditional posterior revision approach without removal of the existing two-level rod in an ASD revision scenario.
Adjacent segment disease in the lumbar spine following different treatment interventions.
Radcliff Kristen E,Kepler Christopher K,Jakoi Andre,Sidhu Gursukhman S,Rihn Jeffrey,Vaccaro Alexander R,Albert Todd J,Hilibrand Alan S
The spine journal : official journal of the North American Spine Society
BACKGROUND CONTEXT:Adjacent segment disease (ASD) is symptomatic deterioration of spinal levels adjacent to the site of a previous fusion. A critical issue related to ASD is whether deterioration of spinal segments adjacent to a fusion is due to the spinal intervention or due to the natural history of spinal degenerative disease. PURPOSE:The purpose of this review is to summarize the recent clinical literature on adjacent segment disease in light of the natural history, patient-modifiable risk factors, surgical risk factors, sagittal balance, and new technology. STUDY DESIGN:This review will evaluate the recent literature on genetic and hereditary components of spinal degenerative disease and potential links to the development of ASD. METHODS:After a meticulous search of Medline for relevant articles pertaining to our review, we summarized the recent literature on the rate of ASD and the effect of various interventions, including motion preservation, sagittal imbalance, arthroplasty, and minimally invasive surgery. RESULTS:The reported rate of ASD after decompression and stabilization procedures is approximately 2% to 3% per year. The factors that are consistently associated with adjacent segment disease include laminectomy adjacent to a fusion and a sagittal imbalance. CONCLUSIONS:Spinal surgical interventions have been associated with ASD. However, whether such interventions may lead to an acceleration of the natural history of the disease remains questionable.
Adjacent Segment Disease in the Cervical and Lumbar Spine.
Tobert Daniel G,Antoci Valentin,Patel Shaun P,Saadat Ehsan,Bono Christopher M
Clinical spine surgery
Adjacent segment disease (ASD) is disappointing long-term outcome for both the patient and clinician. In contrast to adjacent segment degeneration, which is a common radiographic finding, ASD is less common. The incidence of ASD in both the cervical and lumbar spine is between 2% and 4% per year, and ASD is a significant contributor to reoperation rates after spinal arthrodesis. The etiology of ASD is multifactorial, stemming from existing spondylosis at adjacent levels, predisposed risk to degenerative changes, and altered biomechanical forces near a previous fusion site. Numerous studies have sought to identify both patient and surgical risk factors for ASD, but a consistent, sole predictor has yet to be found. Spinal arthroplasty techniques seek to preserve physiological biomechanics, thereby minimizing the risk of ASD, and long-term clinical outcome studies will help quantify its efficacy. Treatment strategies for ASD are initially nonoperative, provided a progressive neurological deficit is not present. The spine surgeon is afforded many surgical strategies once operative treatment is elected. The goal of this manuscript is to consider the etiologies of ASD, review its manifestations, and offer an approach to treatment.
Relationship between sagittal balance and adjacent segment disease in surgical treatment of degenerative lumbar spine disease: meta-analysis and implications for choice of fusion technique.
Phan Kevin,Nazareth Alexander,Hussain Awais K,Dmytriw Adam A,Nambiar Mithun,Nguyen Damian,Kerferd Jack,Phan Steven,Sutterlin Chet,Cho Samuel K,Mobbs Ralph J
European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
STUDY DESIGN:Meta-analysis. OBJECTIVE:To conduct a meta-analysis investigating the relationship between spinopelvic alignment parameters and development of adjacent level disease (ALD) following lumbar fusion for degenerative disease. ALD is a degenerative pathology that develops at mobile segments above or below fused spinal segments. Patient outcomes are worse, and the likelihood of requiring revision surgery is higher in ALD compared to patients without ALD. Spinopelvic sagittal alignment has been found to have a significant effect on outcomes post-fusion; however, studies investigating the relationship between spinopelvic sagittal alignment parameters and ALD in degenerative lumbar disease are limited. METHODS:Six e-databases were searched. Predefined endpoints were extracted and meta-analyzed from the identified studies. RESULTS:There was a significantly larger pre-operative PT in the ALD cohort versus control (WMD 3.99, CI 1.97-6.00, p = 0.0001), a smaller pre-operative SS (WMD - 2.74; CI - 5.14 to 0.34, p = 0.03), and a smaller pre-operative LL (WMD - 4.76; CI - 7.66 to 1.86, p = 0.001). There was a significantly larger pre-operative PI-LL in the ALD cohort (WMD 8.74; CI 3.12-14.37, p = 0.002). There was a significantly larger postoperative PI in the ALD cohort (WMD 2.08; CI 0.26-3.90, p = 0.03) and a larger postoperative PT (WMD 5.23; CI 3.18-7.27, p < 0.00001). CONCLUSION:The sagittal parameters: PT, SS, PI-LL, and LL may predict development of ALD in patients' post-lumbar fusion for degenerative disease. Decision-making aimed at correcting these parameters may decrease risk of developing ALD in this cohort. These slides can be retrieved under Electronic Supplementary Material.
Etiology-Based Classification of Adjacent Segment Disease Following Lumbar Spine Fusion.
Louie Philip K,Harada Garrett K,Sayari Arash J,Mayo Benjamin C,Khan Jannat M,Varthi Arya G,Yacob Alem,Samartzis Dino,An Howard S
HSS journal : the musculoskeletal journal of Hospital for Special Surgery
Background:Adjacent segment disease (ASDz) is a potential complication following lumbar spinal fusion. A common nomenclature based on etiology and ASDz type does not exist and is needed to assist with clinical prognostication, decision making, and management. Questions/Purposes:The objective of this study was to develop an etiology-based classification system for ASDz following lumbar fusion. Methods:We conducted a retrospective chart review of 65 consecutive patients who had undergone both a lumbar fusion performed by a single surgeon and a subsequent procedure for ASDz. We established an etiology-based classification system for lumbar ASDz with the following six categories: "degenerative" (degenerative disc disease or spondylosis), "neurologic" (disc herniation, stenosis), "instability" (spondylolisthesis, rotatory subluxation), "deformity" (scoliosis, kyphosis), "complex" (fracture, infection), or "combined." Based on this scheme, we determined the rate of ASDz in each etiologic category. Results:Of the 65 patients, 27 (41.5%) underwent surgery for neurogenic claudication or radiculopathy for adjacent-level stenosis or disc herniation and were classified as "neurologic." Ten patients (15.4%) had progressive degenerative disc pathology at the adjacent level and were classified as "degenerative." Ten patients (15.4%) had spondylolisthesis or instability and were classified as "instability," and three patients (4.6%) required revision surgery for adjacent-level kyphosis or scoliosis and were classified as "deformity." Fifteen patients (23.1%) had multiple diagnoses that included a combination of categories and were classified as "combined." Conclusion:This is the first study to propose an etiology-based classification scheme of ASDz following lumbar spine fusion. This simple classification system may allow for the grouping and standardization of patients with similar pathologies and thus for more specific pre-operative diagnoses, personalized treatments, and improved outcome analyses.
Risk of adjacent-segment disease requiring surgery after short lumbar fusion: results of the French Spine Surgery Society Series.
Scemama Caroline,Magrino Baptiste,Gillet Philippe,Guigui Pierre
Journal of neurosurgery. Spine
OBJECTIVE Adjacent-segment disease (ASD) is an increasingly problematic complication following lumbar fusion surgery. The purpose of the current study was to determine the risk of ASD requiring surgical treatment after short lumbar or lumbosacral fusion. Primary spinal disease and surgical factors associated with an increased risk of revision were also investigated. METHODS This was a retrospective cohort study using the French Spine Surgery Society clinical data that included 3338 patients, with an average follow-up duration of 7 years (range 4-10 years). Clinical ASD requiring surgery was the principal judgment criterion; the length of follow-up time and initial spinal disease were also recorded. Kaplan-Meier survival analysis was performed. The correlation between primary spinal disease and surgery with an increased risk of revision was investigated. RESULTS During the follow-up period, 186 patients required revision surgery for ASD (5.6%). The predicted risk of ASD requiring revision surgery was 1.7% (95% CI 1.3%-2.2%) at 2 years, 3.8% (95% CI 4.9%-6.7%) at 4 years, 5.7% (95% CI 4.9%-6.7%) at 6 years, and 9% (95% CI 8.7%-10.6%) at 8 years. Initial spinal disease affected the risk of ASD requiring surgery (p = 0.0003). The highest risk was observed for degenerative spondylolisthesis. CONCLUSIONS ASD requiring revision surgery was predicted in 5.6% of patients 7 years after index short lumbar spinal fusion in the French Spine Surgery Society retrospective series. An increased risk of ASD requiring revision surgery associated with initial spinal disease showed the significance of the influence of natural degenerative history on adjacent-segment pathology.
Impact of body mass index on adjacent segment disease after lumbar fusion for degenerative spine disease.
Ou Chien-Yu,Lee Tao-Chen,Lee Tsung-Han,Huang Yu-Hua
BACKGROUND:Adjacent segment disease is an important complication after fusion of degenerative lumbar spines. However, the role of body mass index (BMI) in adjacent segment disease has been addressed less. OBJECTIVE:To examine the relationship between BMI and adjacent segment disease after lumbar fusion for degenerative spine diseases. METHODS:For this retrospective study, we enrolled 190 patients undergoing lumbar fusion surgery for degeneration. BMI at admission was documented. Adjacent segment disease was defined by integration of the clinical presentations and radiographic criteria based on the morphology of the dural sac on magnetic resonance images. RESULTS:Adjacent segment disease was identified in 13 of the 190 patients, accounting for 6.8%. The interval between surgery and diagnosis as adjacent segment disease ranged from 21 to 66 months. Five of the 13 patients required subsequent surgical intervention for clinically relevant adjacent segment disease. In the logistic regression model, BMI was a risk factor for adjacent segment disease after lumbar fusion for degenerative spine diseases (odds ratio, 1.68; 95% confidence interval, 1.27-2.21; P < .001). Any increase of 1 mean value in BMI would increase the adjacent segment disease rate by 67.6%. The patients were subdivided into 2 groups based on BMI, and up to 11.9% of patients with BMI ≥ 25 kg/m were diagnosed as having adjacent segment disease at the last follow-up. CONCLUSION:BMI is a risk factor for adjacent segment disease in patients undergoing lumbar fusion for degenerative spine diseases. Because BMI is clinically objective and modifiable, controlling body weight before or after surgery may provide opportunities to reduce the rate of adjacent segment disease and to improve the outcome of fusion surgery.
Full-endoscopic transforaminal procedure to treat the single-level adjacent segment disease after posterior lumbar spine fusion: 1-2 years follow-up.
Liu Xiao Ming,Liu Zhong Han,Pan Ya Qin,Huang Yu Feng,Wu De Sheng,Ba Zhao Yu
Mathematical biosciences and engineering : MBE
Adjacent segment disease (ASD) is one of the potential risks after lumbar spine surgery with instrumentation. Revision surgery needs to be performed on patients suffered from ASD. The traditional open surgery takes severe injury to the body. We investigated the clinical outcome of using full-endoscopic transforaminal procedure to treat the single-level adjacent segment diseases after posterior lumbar fusion. 33 patients (average 71 years, ranged 65-84 years old) underwent full-endoscopic transforaminal procedure were involved. The Oswestry Disability Index (ODI), Modified Japanese Orthopedic Association (mJOA) score and visual analogue scale (VAS) score were used to evaluate the clinical effect. The complication, hospital stay, hospitalization costs and blood loss were investigated according to the patient's records. The mean VAS score was 1.8 and mJOA score was 5.4 postoperatively. Improvement rate was 78%. The mean ODI was 14.6 postoperatively. The mean length of hospital stay, hospitalization costs and blood loss was 2.5 days, $3500 and 15 mL, respectively. No complication or recurrence was observed in any of the patients at the final follow-up. Full-endoscopic transforaminal procedure is a safe and effective technique. It is economical, acceptable and mini-invasive. Of course, it also can shorten the length of hospital stay and decrease bleeding. For revision surgery to treat ASD, this technique can achieve good clinical effects.
A Biomechanical Analysis of Lateral Interbody Construct and Supplemental Fixation in Adjacent-Segment Disease of the Lumbar Spine.
McMains M Craig,Jain Nikhil,Malik Azeem Tariq,Cerier Emily,Litsky Alan S,Yu Elizabeth
OBJECTIVE:To analyze the stability of lateral lumbar interbody fusion (LLIF) and compare various methods of supplemental fixation in adjacent-segment disease. METHODS:Four fresh-frozen human cadaveric lumbar spines (L1 to sacrum) were used for motion analysis in extension, flexion, and lateral bending. The L4-L5 level was secured with a lateral interbody cage and pedicle screws to simulate a fused segment. The adjacent segment (L3-L4) was evaluated with flexibility testing sequentially under the following conditions: native disc (control), LLIF cage, cage with lateral plate, pedicle screws with z-rod, and single-rod construct. The difference in mean displacement (millimeters) between groups was studied by the analysis of variance and post-hoc Tukey test. RESULTS:Mean displacement (millimeters) on averaging motion in all planes was 0.741 for native disc, 0.273 for cage, 0.183 for cage with plate, 0.086 for pedicle screws and z-rod, and 0.106 for the single-rod construct. All 4 constructs led to a significant reduction (P < 0.001) in displacement in extension and flexion, as compared with native disc. There was no demonstrable superiority between the 4 constructs as the mean displacements were not significantly different from each other. CONCLUSIONS:LLIF with and without supplemental fixation reduced motion significantly at the adjacent segment as compared with intact disc. There was a trend toward increasing rigidity with supplemental fixation (plate and pedicle screw constructs). Further biomechanical studies with larger sample sizes are needed to confirm these initial findings.
Influence of cement-augmented pedicle screw instrumentation in an osteoporotic lumbosacral spine over the adjacent segments: a 3D finite element study.
Zhou Quan-Kun,Zeng Fan-Hui,Tu Jian-Long,Dong Zhang-Qing,Ding Zhi-Hui
Journal of orthopaedic surgery and research
PURPOSE:To compare the effect of conventional pedicle screw (CPS) and cement-augmented pedicle screw instrumentation (CAPSI) on adjacent segment degeneration (ASD). METHODS:A normal male volunteer without a history of spinal disease was selected, lumbar CT data was collected, an intact L3-S1 three-dimensional finite element model was created by software including Mimics, Geomagic, and SolidWorks, and the fixation methods were performed accordingly. A common pedicle screw model and a cement-augmented pedicle screw model of L4-L5 with fusion and internal fixation were constructed. With ANSYS Workbench 17.0, a 500 N load was applied to the upper surface of L3 to simulate the weight of a human body, and a 7.5 N m moment was applied at the neutral point to simulate flexion, extension, left/right bending, left/right rotation of the spine. The peak von Mises stress of intervertebral disc and the range of motion (ROM) on the adjacent segments (L3-4 and L5-S1) were compared. RESULTS:The validity of the intact model shows that the ROM of the model is similar to that of a cadaveric study. Compared with the intact model, CPS model and CAPSI model in all motion patterns increased the ROM of adjacent segments. The intervertebral disc stress and the ROM of adjacent segments were found to be higher in the CAPSI model than in the CPS model, especially in L3-4. CONCLUSION:In general, the biomechanical analysis of an osteoporotic lumbar spine showed that both CPS and CAPSI can increase the ROM and disc stresses of osteoporotic lumbar models, and compared with CPS, CAPSI is more likely to increase the potential risk of adjacent segment degeneration.
Minimally invasive options for surgical management of adjacent segment disease of the lumbar spine.
Turel Mazda K,Kerolus Mena G,David Brian T,Fessler Richard G
Background:The incidence of adjacent segment disease (ASD) after lumbar spine surgery is a condition that has become increasingly common as the rate of lumbar spine surgery continues to rise. Minimally invasive techniques continue to be refined and offer an opportunity to treat ASD with minimal tissue disruption, lower blood loss, a shorter hospital stay, and decreased morbidity. The aim of this report is to describe the various minimally invasive options for ASD with a comprehensive review of the existing literature. Materials and Methods:A retrospective chart review of patients undergoing minimally invasive spine surgery (MIS) for ASD of the lumbar spine was conducted. Four basic techniques and their modifications were identified to address ASD. Illustrative cases, surgical techniques, and post-surgical outcomes are described. Results:Four MIS techniques were identified as common surgical methods to correct ASD. (1) Non-instrumented discectomy, foraminotomy, or decompression, (2) anterior lumbar interbody fusion (ALIF), (3) transforaminal lumbar interbody fusion (TLIF), and (4) lateral lumbar interbody fusion (LLIF) were found to be MIS techniques that address ASD. ALIF and LLIF provide indirect decompression of the neural foramina, while TLIF provides direct decompression. The addition and removal of screws and rods can be combined with any of these techniques. Conclusions:MIS techniques provide decompression of the neural elements, stabilization, and, potentially, fusion for patients with ASD. These illustrated cases and the review of MIS surgical techniques can provide a comprehensive framework for addressing ASD.
A less invasive treatment by a full-endoscopic spine surgery for adjacent segment disease after lumbar interbody fusion.
Iwai Hiroki,Oshima Yasushi,Kitagawa Tomoaki,Inoue Hirokazu,Takano Yuichi,Inanami Hirohiko,Koga Hisashi
Journal of spine surgery (Hong Kong)
Background:Full-endoscopic spine surgery (FESS) is a suitable treatment for lumbar disc herniation (LDH) and foraminal stenosis. This study investigated the usefulness of FESS in treating adjacent segment disease (ASD) after lumbar interbody fusion (LIF). Methods:Between September 2015 and March 2019, a total of 13 patients with symptomatic ASD after LIF underwent FESS. Discectomy and foraminoplasty using a 3.5-mm diameter high-speed drill were performed for treating LDH and foraminal stenosis. Preoperative and postoperative statuses were evaluated using Numerical Rating Scale (NRS) and the modified Japanese Orthopedic Association (mJOA) scores. Results:The patients' mean age was 64.8 years; there were 10 male and 3 female patients. The mean operative time was 52.7 min. The mean pre- and postoperative NRS scores were 7.6 and 3.1, respectively. The mean pre- and postoperative mJOA scores were 10.5 and 16.1, respectively, and the mean recovery rate was 32.8%. Subsequent operative treatments were required in 3 patients for postoperative complication, insufficient decompression, and recurrence LDH. Conclusions:FESS is a safe and effective minimally invasive treatment for ASD after LIF and a potential alternative to extend the LIF to the adjacent vertebra or sacrum.