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Multiple-Repeated Adjacent Segment Disease After Posterior Lumbar Interbody Fusion
Original Article
Multiple-Repeated Adjacent Segment Disease After Posterior Lumbar Interbody Fusion Yukitaka Nagamoto, Shinya Okuda, Tomiya Matsumoto, Tsuyoshi Sugiura, Yoshifumi Takahashi, Motoki Iwasaki
BACKGROUND: Although posterior lumbar interbody fusion (PLIF) has provided satisfactory clinical outcomes, adjacent segment disease (ASD) is one of the most important complications affecting long-term results. However, according to ASD studies, few have described repeat surgery. The purpose of this study was to elucidate incidence, time period, and clinical features of multiplerepeated ASD after PLIF.
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METHODS: Subjects comprised 1112 consecutive patients (502 men, 610 women) who underwent 1-level PLIF for degenerative lumbar diseases. The mean age of patients was 66 years (range, 15e89). The mean follow-up period was 6.4 years (range, 0.5e21.1). The incidence and the time period of multiple-repeated ASD were investigated. To elucidate clinical features of the multiple-repeated ASD, all 4 cases were shown as the case description including radiographic parameters.
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RESULTS: Four (0.4%) developed multiple-repeated ASD: 3 women and 1 man. Primary PLIF was performed at L3-4 in 1 patient and at L4-5 in 3 patients. Two patients underwent adjacent segment decompression simultaneously. All patients required at least 3 additional surgeries due to newly occurred ASD after each PLIF. All patients developed iatrogenic flatback as ASD was repeated. As a result, corrective surgeries were required (thoracolumbar, 2; spinopelvic, 2).
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CONCLUSIONS: Multiple-repeated ASD was observed in 0.4% of the patients. All patients developed iatrogenic
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Key words Adjacent segment disease - Complication - Iatrogenic flatback - Lumbar fusion - Posterior lumbar interbody fusion - Sagittal imbalance -
Abbreviations and Acronyms ASD: Adjacent segment disease DS: Degenerative spondylolisthesis LSS: Lumbar spinal canal stenosis PI-LL: Pelvic incidencelumbar lordosis PLIF: Posterior lumbar interbody fusion
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flatback as a result of repeated ASD, and corrective surgeries were required for these patients.
INTRODUCTION
A
mong various fusion techniques, posterior lumbar interbody fusion (PLIF) has the advantage of both circumferential decompression and fusion and has provided satisfactory clinical outcomes and high fusion rates.1-4 More than a quarter of a century has passed since PLIF became a standard treatment for lumbar degenerative diseases. PLIF has evolved into a minimally invasive technique and is still one of the most popular fusion techniques. However, adjacent segment disease (ASD) is one of the most important complications affecting long-term results. According to previous reports, the incidence of additional surgery for ASD after fusion surgery ranges from 2.6%27. 4%.1,2,5-12 As the follow-up period increases, the incidence and number of additional surgeries appear to become more frequent. However, among many ASD studies, few have described repeat surgeries due to ASD and no literature focused on cases that required 3 or more additional surgeries due to repeated ASD.13-17 In our institute, of the 1112 patients who underwent 1-level PLIF with or without adjacent segment decompression, four (0.4%) developed multiple-repeated ASD. Although its pathology remains unclear, multiple-repeated ASD is predicted to increase as the number of PLIF increases. The purpose of this study was to elucidate incidence, time period, and clinical features of multiple-repeated ASD after PLIF through the report of 4 cases.
PSO: Pedicle subtraction osteotomy S2AI: S2 alar-iliac screw Department of Orthopaedic Surgery, Osaka Rosai Hospital, Sakai, Japan To whom correspondence should be addressed: Yukitaka Nagamoto, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.09.227 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
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In this study, ASD was defined as a symptomatic condition in which additional surgery was required to treat neurologic deterioration at the adjacent degenerative segment. Repeated ASD was defined as a condition in which additional surgery was required at the further adjacent segment of the secondary PLIF, at the segment adjacent to the primary PLIF. Multiple-repeated ASD was defined as a condition in which additional surgery was required 3 times or more due to repeated ASD. Repeated ASD and multiplerepeated ASD were equivalent to the second and third or more instances of ASD, respectively.
MATERIAL AND METHODS
SURGICAL INDICATIONS AND PROCEDURES
Study Population From 1996e2017, 1112 consecutive patients (502 men, 610 women) underwent 1-level PLIF for degenerative lumbar diseases. The mean age at the time of surgery was 66 years (range, 15e89 years). The follow-up rate was 55.4%, and the mean follow-up period was 6.4 years (range, 0.5e21.1 years). Overall, 940 patients (91.0%) had >2 years of follow-up, 614 (74.7%) had >5 years of follow-up, and 1.81 (54.6%) had >10 years of follow-up. The patients had 1 of the following diagnoses: degenerative spondylolisthesis (DS, n ¼ 712), isthmic spondylolisthesis (n ¼ 165), lumbar spinal canal stenosis (LSS, n ¼ 95, 10 were restenosis after decompression surgery),
Figure 1. Flow chart diagram describing repeated ASD. N, number of patients; ASD, adjacent segment disease; y, years; 1 PLIF, 1-level posterior lumbar interbody fusion; AD, adjacent segment decompression; APLF, adjacent segment
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degenerative lumbar scoliosis (n ¼ 65), and lumbar disk herniation (LDH, n ¼ 75). Degenerative lumbar scoliosis was defined as lumbar scoliosis more than 20 degrees or local disk wedging >10 degrees. Patients who had infection, trauma, rheumatoid arthritis, or destructive spinal arthropathy were excluded. Overall, 247 patients underwent adjacent segment decompression simultaneously and 227 patients received bilateral (1 level, 161; 2 levels, 53; 3 levels, 13) laminectomy, 5 patients received 1-level unilateral partial laminectomy, 13 received a diskectomy, and 2 received a total laminectomy. This study was approved by the Research Ethics Committee of Osaka Rosai Hospital.
All patients had severe, disabling lower limb pain with or without low back pain unresponsive to conservative treatment. The indications for PLIF were as follows: spondylolisthesis with slippage >3 mm with a posterior opening >5 degrees on flexion radiographs, lumbar spine stenosis with foraminal stenosis of the same segment, or a huge central lumbar disk hernia requiring wide decompression. All PLIF procedures were performed using the same technique described previously.18 Our PLIF procedure included a bilateral total facetectomy, subtotal diskectomy, a large amount of autologous bone graft with 2 carbon cages, and pedicle screw fixation. We believe that a wide surgical field provides
posterolateral fusion; and 2 fusion, 2-levels or more spinal fusion. (*P < 0.05, Mann-Whitney U test, **P < 0.05, analysis of variance with Bonferroni post-hoc test.)
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advantages for installation of a large amount of autologous bone graft and acquisition of a large segmental lordosis. OUTCOME MEASURES The incidence and time periods of multiple-repeated ASD were investigated. To elucidate clinical features of the multiple-repeated ASD, all 4 cases were shown as the case description including radiographic parameters. STATISTICAL ANALYSIS To assess the statistical difference in the incidence and time period between primary PLIF to first ASD and first to second ASD and between first to second ASD and second to third ASD, a Mann-Whitney U test was performed. To assess the statistical difference in the incidence according to surgical procedure, a Mann-Whitney U test was performed in the first ASD and an analysis of variance (ANOVA) using a Bonferroni post-hoc test was
Figure 2. Lateral standing radiographs of the whole spine in Case 1 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). BPL, bilateral partial laminectomy; EBL, estimated blood loss; DS, degenerative spondylolisthesis; F, female; LS,
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performed in the second and third ASD. A P value < 0.05 was considered significant. All statistical analyses were conducted using SPSS Statistics for Windows version 21 (IBM Corp. Chicago, Illinois, USA). RESULTS Incidence and Time Periods of Multiple-Repeated Adjacent Segment Disease After PLIF A total of 116 patients (10.4%) developed the first ASD 5.4 years after the primary PLIF, 14 patients (12.0% of the first ASD patients, 1.3% of the total) developed the second ASD (repeated ASD) 3.3 years after the last surgery, and 4 patients (28.6% of the second ASD patients, 0.4% of the total) developed the third ASD (multiplerepeated ASD) 1.5 years after the last surgery (Figure 1). There were no significant differences in the incidence (P ¼ 0.59, between primary PLIF to first ASD and first to second ASD; P ¼ 0.09 between first to second ASD and second to third ASD) and time
lumbosacral; LSS, lumbar spinal canal stenosis; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; y.o, years old.
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periods (P ¼ 0.12, between primary PLIF to first ASD and first to second ASD; P ¼ 0.12 between first to second ASD and second to third ASD). As for multiple-repeated ASD patients, the first ASD occurred at an average of 3.0 years after the primary PLIF, while in overall, at an average of 5.4 years. In cases with a third ASD, the first ASD tended to occur earlier with no statistical significance (P ¼ 0.27, Case 1, 1.4 years; Case 2, 5.4 years; Case 3, 3.1 years; Case 4, 2.0 years). In terms of ASD by surgical procedures, no difference was detected in the ASD incidence between PLIF alone and PLIF with adjacent segment decompression simultaneously (P ¼ 0.91). Of the 37 first ASD patients who underwent PLIF with adjacent segment decompression simultaneously at primary surgery, 25 patients developed ASD at the adjacent decompression segment, while 12 patients developed ASD at levels other than that of the previous decompression (Figure 1).
Figure 3. Lateral standing radiographs of the whole spine in Case 2 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). BPL, bilateral partial laminectomy; EBL, estimated blood loss; DS, degenerative spondylolisthesis; F, female; LS,
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CASE DESCRIPTION Case 1 Primary Surgery. A 69-year-old woman who had a history of hypertension and insulin-dependent diabetes complained of bilateral lower limb pain and intermittent claudication. Plain radiographs showed L3 DS, and a preoperative myelogram showed an incomplete block at the L2-4 segment. She underwent PLIF at L3-4 and concomitant partial laminectomy at L2-3 (Figure 2A). Clinical Course to Multiple-Repeated Adjacent Segment Disease. Although this patient’s symptoms resolved after primary surgery, de novo L2 DS was observed at 1 year after primary surgery and her neurologic symptoms gradually deteriorated. At 1.4 years after primary surgery, PLIF at L2-3 was performed for the first ASD (Figure 2B). However, canal stenosis with kyphotic deformity at L1-2 appeared and gradually progressed after the
lumbosacral; LSS, lumbar spinal canal stenosis; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; VC, vertebral collapse; VCR, vertebral column resection; y.o, years old.
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second surgery (Figure 2C). Her neurologic symptoms deteriorated again and intractable low back pain emerged. At 5.8 years after the second surgery, PLIF at L1-2 and pedicle subtraction osteotomy (PSO) at L2, with pedicle screw fixation between T4 and L5, was performed for the second ASD. Furthermore, a kyphotic deformity at the lumbosacral junction was observed only 2 months after the last surgery and, again, intractable low back pain was noted. At 5 months after the last surgery, PLIF at L5-S and PSO at L5, with an extension of the pedicle screw fixation to the pelvis using an S2 alar-iliac (S2AI) screw, were performed for the third ASD (Figure 2D). Her symptoms and sagittal imbalance improved. Latest Status. The pedicle screw fixation was extended to T1 due to proximal junctional failure at T3-4 at 9 months after the fourth surgery. However, at 10.0 years after the primary surgery, her global sagittal balance was maintained and she could walk with a cane (Figure 2E).
Figure 4. Lateral standing radiographs of the whole spine in Case 3 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). BPL, bilateral partial laminectomy; DH, disk hernia; EBL, estimated blood loss; DS, degenerative spondylolisthesis;
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Case 2 A 61-year-old woman who had a history of insulin-dependent diabetes underwent PLIF at L4-5 for L4 DS (Figure 3A). Both the first and second ASDs were de novo DS at the upper adjacent segment, and PLIF was performed twice for her recurrent neurologic symptoms at L3-4 (Figure 3B) and L2-3 (Figure 3C). After a stepwise L2-5 fusion, a kyphotic deformity at the proximal junction of the fusion mass was noted as an L1 spontaneous vertebral collapse (Figure 3D). The third ASD was a kyphotic deformity with stenosis at the proximal junctional segment. A vertebral column resection at L1 and replacement of titanium mesh cages with pedicle screw fixation between T4 and L5 were performed for her gait changes, intractable low back pain and fatigue, and recurrent neurologic symptoms. At the latest follow-up (13.8 years after the primary surgery, Figure 3E), her global sagittal imbalance had gradually progressed at the lumbosacral junction. Although her lower-limb pain had
F, female; LS, lumbosacral; LSS, lumbar spinal canal stenosis; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; y.o, years old.
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resolved, she could only walk for 5 minutes with a cart because of low back pain. Corrective surgery was planned but abandoned due to cardiac dysfunction. This patient died of cardiac dysfunction 5 years after the last surgery. Case 3 A 66-year-old woman who had no past medical history underwent PLIF at L4-5 and concomitant partial laminectomy at L3-4 for L4 DS and L3-4 LSS (Figure 4A). The first ASD involved de novo DS at the upper adjacent segment, and PLIF was performed for her recurrent neurologic symptom at L3-4 (Figure 4B). However, her lumbar lordosis decreased as a result of stepwise L3-5 fusion. The second ASD was a large disk herniation at the proximal junction of the fusion mass with low lumbar lordosis (Figure 4C). PLIF at L2-3 and PSO at L3 with pedicle screw fixation between T10 and L6 were performed for her recurrent neurologic symptom. The third ASD was a kyphotic deformity at the lumbosacral junction
Figure 5. Radiographs of Case 4 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). The films before the first (A) and second (B) surgery were lateral standing radiographs of the lumbar spine during myelography, and the other films were lateral standing radiographs of the whole spine. Before the third surgery (C), no implantation was observed because all implantation was
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because L6-S segment was left mobile (Figure 4D). PLIF at L5-6 and PSO at L6 with an extension of the pedicle screw fixation to the pelvis using an S2AI screw were performed for her intractable low back pain and fatigue. At the latest follow-up (9.5 years after the primary surgery, Figure 4E), her global sagittal balance was maintained. She could walk using a cart without low back pain though residual lower extremity weakness remained. Case 4 A 64-year-old man who had a history of depression underwent PLIF at L4-5 for L4 DS (Figure 5A). The first ASD was a de novo LSS at L2-4 (Figure 5B). A partial laminectomy at L2-4 was performed for his neurologic symptoms. The second ASD was DS at decompression segments (Figure 5C). PLIF at L2-4 was performed for his neurologic symptoms. However, the third ASD was de novo LSS at L1-2 with low lumbar lordosis (Figure 5D). A partial laminectomy at L1-2 with pedicle screw fixation between T9 and
removed at the second surgery. BPL, bilateral partial laminectomy; EBL, estimated blood loss; DS, degenerative spondylolisthesis; F, female; LS, lumbosacral; LSS, lumbar spinal canal stenosis; M, male; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; y.o, years old.
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Figure 6. Clinical course of the global sagittal alignment. SVA (A), LL (B), PT (C), and PI-LL (D). FU, follow-up; LL, lumbar lordosis; N/A, whole spine images were not
L4 was performed for his neurologic symptoms. However, the additional fusion ended up worsening the postoperative sagittal alignment because the application of the lumbar lordosis was insufficient. At the latest follow-up (15.8 years after the primary surgery, Figure 5E), his global sagittal balance was noted to have deteriorated gradually; nevertheless, he could walk freely without assistance. The clinical course of the global sagittal alignment and the local sagittal alignment after the primary surgery in the 4 cases is shown in Figure 6 and Table 1, respectively. DISCUSSION Frequency and Clinical Features of Repeated Adjacent Segment Disease Several studies have been conducted on the results of reoperation for ASD after lumbar fusion, and 4 of them found that 4.5%12.1% of ASD patients developed repeated ASD.13-17 As for multiple-repeated ASD, Phillips et al16 reported 33 cases of ASD patients who experienced lumbar fusion, four (12.1% of the first ASD patients) had developed a second ASD and in the four, and two (50% of the second ASD patients) developed a third ASD. However, the study lacked description of the population of primary surgery and details of the third ASD cases.16 The present results indicating that 12% of those with a first ASD developed a second ASD and 28.6% of those with a second ASD developed a third ASD were acceptable compared with the previous reports. Patients with 1 reoperation after lumbar surgery are at considerable risk for needing further
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available; PI, pelvic incidence; PT, pelvic tilt; SVA, sagittal vertical axis.
lumbar surgeries.19 Also in ASD cases, the surgical rate had a tendency to increase and the interval between surgeries reduced as the ASD repeated. In addition, the first ASD in the 4 patients who had a third ASD occurred at an average of 3 years after the primary PLIF, while in overall, at an average of 5.4 years. In cases with a third ASD, the first ASD tended to occur earlier. All patients with multiple-repeated ASD complained of neurologic symptoms in the lower limb during the first ASD. However, they developed an iatrogenic flatback as a result of repeated PLIFs for ASD and complained of thoracolumbar symptoms, such as standing and gait disturbance along with intractable low back pain and/or fatigue in addition to neurologic symptoms in the lower limb associated with the second or later ASD. Although the diagnoses and operative treatments were done appropriately at every revision surgery, all of the patients finally
Table 1. Local Sagittal Alignment at Posterior Lumbar Interbody Fusion Level After Primary Operation Intervertebral Level
SL (degrees)
DA (degrees)
Case 1
L3-4
0
4
Case 2
L4-5
9
1
Case 3
L4-5
4
4
Case 4
L4-5
5
0
Both SL and DA were measured at the surgical intervertebral level. SL, segmental lordosis; DA, disk angle.
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required corrective surgery for the iatrogenic flatback in order to achieve sagittal balance and their activities of daily living gradually deteriorated as the surgeries were repeated. Risk Factors for Adjacent Segment Disease Among various reported risk factors of ASD, some studies have reported adjacent segment decompression as the risk factor.20-22 In the present series, no difference was detected in the ASD incidence between PLIF alone and PLIF with adjacent segment decompression simultaneously. Several studies have reported that abnormal sagittal balance and/or parameters could be responsible for ASD after lumbar fusion, and the following factors have been identified: less severe lumbar lordosis,23,24 smaller sacral slope,25,26 greater pelvic tilt,24,25 greater sagittal vertical axis,24 greater pelvic incidence,9 and greater pelvic incidencelumbar lordosis (PI-LL).24,27,28 In the present series, all patients lost their lumbar lordosis and subsequently developed iatrogenic flatback as ASD was repeated, as shown in Figure 6AeD. Among sagittal parameters, only segmental lordosis could be managed during the PLIF procedures. Kim et al29 showed that a low postoperative segmental lordosis at L4-5, in particular <20 degrees, at the index level was related to the development of clinical ASD. We also performed a risk factor analysis for ASD regarding spinopelvic parameters and concluded that postoperative PI-LL was a major risk factor for ASD and postoperative lumbar lordosis was correlated with segmental lordosis at the fused segment.24 In the current 4 patients, segmental lordosis and disk angle at the primary PLIF appeared to be insufficient, ranging from 0 to 9 degrees and 4 to 1 degree (see Table 1). From previous reports and the present results, surgeons should endeavor to achieve adequate segmental lordosis using techniques, such as the forward installation of a bone graft with cages, use of hyper wedge cages, and compression.24,29 Even when ASD occurs, adequate segmental lordosis at the first surgery could reduce the invasion of salvage surgery. Treatment Strategies for Adjacent Segment Disease When PLIF was repeated for ASD, most cases demonstrated reduced lumbar lordosis and, subsequently, their global sagittal balance deteriorated along with compensatory thoracic hypokyphosis and pelvis retroversion. In such cases, global alignment should be evaluated as adult spine deformity, in addition to the
REFERENCES 1. Okuda S, Miyauchi A, Oda T, Haku T, Yamamoto T, Iwasaki M. Surgical complications of posterior lumbar interbody fusion with total facetectomy in 251 patients. J Neurosurg Spine. 2006; 4:304-309. 2. Okuda S, Oda T, Miyauchi A, Haku T, Yamamoto T, Iwasaki M. Surgical outcomes of posterior lumbar interbody fusion in elderly patients. J Bone Joint Surg Am. 2006;88:2714-2720. 3. Trouillier H, Birkenmaier C, Rauch A, Weiler C, Kauschke T, Refior HJ. Posterior lumbar interbody fusion (PLIF) with cages and local bone graft in the treatment of spinal stenosis. Acta Orthop Belg. 2006;72:460-466.
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degree of stenosis and instability. Regarding the surgical strategy for a first ASD, if additional PLIF is required, segmental lordosis should be achieved in the aforementioned manner. However, regarding a second or later ASD, corrective surgery should be considered rather than a repeat PLIF for adult spine deformity. With respect to corrective surgery for multiple-repeated ASD, total lumbar fusion to the pelvis appears to have some advantages for the following reasons. First, it is difficult to achieve adequate lumbar lordosis only by lumbar corrective fusion in patients who demonstrate multisegment lumbar fusion. Second, lumbosacral fusion can achieve the correction of compensatory pelvic retroversion. In the present series, the lower instrumented vertebrae of all 4 cases in corrective surgery were the most caudal lumbar vertebrae (L5 or L6). However, 2 patients experienced a rapid deterioration of kyphosis at the lumbosacral junction and complained of standing disturbance with severe low back pain. These 2 patients required an extension of the fixation to the pelvis using an S2AI screw and maintained an adequate sagittal balance at the final follow-up. Limitations First, given the inherent limitation of a 4-patient case report, this study lacked statistical data and risk factors for multiple-repeated ASD could not be elucidated in this study. Second, there was a wide range in the time to follow-up (0.5e21.1 years). The ASD rate and time period would change by the follow-up period, as mentioned earlier. However, the mean follow-up period of 6.4 years and rate of 55.4% were acceptable in such a large and longterm follow-up study.
CONCLUSION We reported 4 cases of multiple-repeated ASD after PLIF, with an incidence of 0.4% over 2 decades. All patients showed insufficient segmental lordosis and disk angle at the primary PLIF and developed iatrogenic flatback due to repeated ASD. Moreover, all patients required thoracolumbar or spinopelvic corrective surgeries. Although the incidence is very low to date, multiplerepeated ASD may become important as the number of affected patients is expected to increase because of increased follow-up periods.
4. Yamamoto T, Ohkohchi T, Ohwada T, Kotoku H, Harada N. Clinical and radiological results of PLIF for degenerative spondylolisthesis. J Musculoskel Res. 1998;2:181-195. 5. Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. Adjacent segment degeneration in the lumbar spine. JBJS. 2004;86:1497-1503. 6. Heo Y, Park JH, Seong HY, Lee Y-S, Jeon SR, Rhim SC, et al. Symptomatic adjacent segment degeneration at the L3e4 level after fusion surgery at the L4e5 level: evaluation of the risk factors and 10-year incidence. Eur Spine J. 2015;24: 2474-2480. 7. Lee CS, Hwang CJ, Lee S-W, Ahn Y-J, Kim Y-T, Lee D-H, et al. Risk factors for adjacent segment
disease after lumbar fusion. Eur Spine J. 2009;18: 1637. 8. Lee JC, Kim Y, Soh J-W, Shin B-J. Risk factors of adjacent segment disease requiring surgery after lumbar spinal fusion: comparison of posterior lumbar interbody fusion and posterolateral fusion. Spine. 2014;39:E339-E345. 9. Nakashima H, Kawakami N, Tsuji T, Ohara T, Suzuki Y, Saito T, et al. Adjacent segment disease after posterior lumbar interbody fusion: based on cases with a minimum of 10 years of follow-up. Spine. 2015;40:E831-E841. 10. Okuda S, Fujimori T, Oda T, Yamasaki R, Maeno T, Yamashita T, et al. Patient-based surgical outcomes of posterior lumbar interbody
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patients undergoing revision surgery. Eur Spine J. 2014;23:693-698. 26. Kumar M, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J. 2001;10:314-319. 27. Rothenfluh DA, Mueller DA, Rothenfluh E, Min K. Pelvic incidence-lumbar lordosis mismatch predisposes to adjacent segment disease after lumbar spinal fusion. Eur Spine J. 2015; 24:1251-1258.
13. Chen W-J, Lai P-L, Niu C-C, Chen L-H, Fu T-S, Wong C-B. Surgical treatment of adjacent instability after lumbar spine fusion. Spine. 2001;26: E519-E524.
21. Lai P-L, Chen L-H, Niu C-C, Fu T-S, Chen W-J. Relation between laminectomy and development of adjacent segment instability after lumbar fusion with pedicle fixation. Spine. 2004;29:2527-2532.
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22. Miyagi M, Ikeda O, Ohtori S, Tsuneizumi Y, Someya Y, Shibayama M, et al. Additional decompression at adjacent segments leads to adjacent segment degeneration after PLIF. Eur Spine J. 2013;22:1877-1883.
29. Kim KH, Lee S-H, Shim CS, Lee DY, Park HS, Pan W-J, et al. Adjacent segment disease after interbody fusion and pedicle screw fixations for isolated L4eL5 spondylolisthesis: a minimum five-year follow-up. Spine. 2010;35:625-634.
15. Miwa T, Sakaura H, Yamashita T, Suzuki S, Ohwada T. Surgical outcomes of additional posterior lumbar interbody fusion for adjacent segment disease after single-level posterior lumbar interbody fusion. Eur Spine J. 2013;22:2864-2868. 16. Phillips FM, Carlson GD, Bohlman HH, Hughes SS. Results of surgery for spinal stenosis adjacent to previous lumbar fusion. Clin Spine Surg. 2000;13:432-437. 17. Wang MY, Vasudevan R, Mindea SA. Minimally invasive lateral interbody fusion for the treatment of rostral adjacent-segment lumbar degenerative stenosis without supplemental pedicle screw fixation. J Neurosurg Spine. 2014;21:861-866. 18. Okuda S, Oda T, Miyauchi A, Haku T, Yamamoto T, Iwasaki M. Surgical outcomes of
23. Djurasovic M, Carreon LY, Glassman SD, Dimar JR, Puno RM, Johnson JR. Sagittal alignment as a risk factor for adjacent level degeneration: a case-control study. Orthopedics. 2008;31. 24. Matsumoto T, Okuda S, Maeno T, Yamashita T, Yamasaki R, Sugiura T, et al. Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion. J Neurosurg Spine. 2017;26: 435-440.
Conflict of interest statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Received 22 July 2018; accepted 28 September 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.09.227 Journal homepage: www.WORLDNEUROSURGERY.org
25. Di Martino A, Quattrocchi CC, Scarciolla L, Papapietro N, Zobel BB, Denaro V. Estimating the risk for symptomatic adjacent segment degeneration after lumbar fusion: analysis from a cohort of
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Multiple-Repeated Adjacent Segment Disease After Posterior Lumbar Interbody Fusion Yukitaka Nagamoto, Shinya Okuda, Tomiya Matsumoto, Tsuyoshi Sugiura, Yoshifumi Takahashi, Motoki Iwasaki
BACKGROUND: Although posterior lumbar interbody fusion (PLIF) has provided satisfactory clinical outcomes, adjacent segment disease (ASD) is one of the most important complications affecting long-term results. However, according to ASD studies, few have described repeat surgery. The purpose of this study was to elucidate incidence, time period, and clinical features of multiplerepeated ASD after PLIF.
-
METHODS: Subjects comprised 1112 consecutive patients (502 men, 610 women) who underwent 1-level PLIF for degenerative lumbar diseases. The mean age of patients was 66 years (range, 15e89). The mean follow-up period was 6.4 years (range, 0.5e21.1). The incidence and the time period of multiple-repeated ASD were investigated. To elucidate clinical features of the multiple-repeated ASD, all 4 cases were shown as the case description including radiographic parameters.
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RESULTS: Four (0.4%) developed multiple-repeated ASD: 3 women and 1 man. Primary PLIF was performed at L3-4 in 1 patient and at L4-5 in 3 patients. Two patients underwent adjacent segment decompression simultaneously. All patients required at least 3 additional surgeries due to newly occurred ASD after each PLIF. All patients developed iatrogenic flatback as ASD was repeated. As a result, corrective surgeries were required (thoracolumbar, 2; spinopelvic, 2).
-
CONCLUSIONS: Multiple-repeated ASD was observed in 0.4% of the patients. All patients developed iatrogenic
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Key words Adjacent segment disease - Complication - Iatrogenic flatback - Lumbar fusion - Posterior lumbar interbody fusion - Sagittal imbalance -
Abbreviations and Acronyms ASD: Adjacent segment disease DS: Degenerative spondylolisthesis LSS: Lumbar spinal canal stenosis PI-LL: Pelvic incidencelumbar lordosis PLIF: Posterior lumbar interbody fusion
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flatback as a result of repeated ASD, and corrective surgeries were required for these patients.
INTRODUCTION
A
mong various fusion techniques, posterior lumbar interbody fusion (PLIF) has the advantage of both circumferential decompression and fusion and has provided satisfactory clinical outcomes and high fusion rates.1-4 More than a quarter of a century has passed since PLIF became a standard treatment for lumbar degenerative diseases. PLIF has evolved into a minimally invasive technique and is still one of the most popular fusion techniques. However, adjacent segment disease (ASD) is one of the most important complications affecting long-term results. According to previous reports, the incidence of additional surgery for ASD after fusion surgery ranges from 2.6%27. 4%.1,2,5-12 As the follow-up period increases, the incidence and number of additional surgeries appear to become more frequent. However, among many ASD studies, few have described repeat surgeries due to ASD and no literature focused on cases that required 3 or more additional surgeries due to repeated ASD.13-17 In our institute, of the 1112 patients who underwent 1-level PLIF with or without adjacent segment decompression, four (0.4%) developed multiple-repeated ASD. Although its pathology remains unclear, multiple-repeated ASD is predicted to increase as the number of PLIF increases. The purpose of this study was to elucidate incidence, time period, and clinical features of multiple-repeated ASD after PLIF through the report of 4 cases.
PSO: Pedicle subtraction osteotomy S2AI: S2 alar-iliac screw Department of Orthopaedic Surgery, Osaka Rosai Hospital, Sakai, Japan To whom correspondence should be addressed: Yukitaka Nagamoto, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.09.227 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
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In this study, ASD was defined as a symptomatic condition in which additional surgery was required to treat neurologic deterioration at the adjacent degenerative segment. Repeated ASD was defined as a condition in which additional surgery was required at the further adjacent segment of the secondary PLIF, at the segment adjacent to the primary PLIF. Multiple-repeated ASD was defined as a condition in which additional surgery was required 3 times or more due to repeated ASD. Repeated ASD and multiplerepeated ASD were equivalent to the second and third or more instances of ASD, respectively.
MATERIAL AND METHODS
SURGICAL INDICATIONS AND PROCEDURES
Study Population From 1996e2017, 1112 consecutive patients (502 men, 610 women) underwent 1-level PLIF for degenerative lumbar diseases. The mean age at the time of surgery was 66 years (range, 15e89 years). The follow-up rate was 55.4%, and the mean follow-up period was 6.4 years (range, 0.5e21.1 years). Overall, 940 patients (91.0%) had >2 years of follow-up, 614 (74.7%) had >5 years of follow-up, and 1.81 (54.6%) had >10 years of follow-up. The patients had 1 of the following diagnoses: degenerative spondylolisthesis (DS, n ¼ 712), isthmic spondylolisthesis (n ¼ 165), lumbar spinal canal stenosis (LSS, n ¼ 95, 10 were restenosis after decompression surgery),
Figure 1. Flow chart diagram describing repeated ASD. N, number of patients; ASD, adjacent segment disease; y, years; 1 PLIF, 1-level posterior lumbar interbody fusion; AD, adjacent segment decompression; APLF, adjacent segment
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degenerative lumbar scoliosis (n ¼ 65), and lumbar disk herniation (LDH, n ¼ 75). Degenerative lumbar scoliosis was defined as lumbar scoliosis more than 20 degrees or local disk wedging >10 degrees. Patients who had infection, trauma, rheumatoid arthritis, or destructive spinal arthropathy were excluded. Overall, 247 patients underwent adjacent segment decompression simultaneously and 227 patients received bilateral (1 level, 161; 2 levels, 53; 3 levels, 13) laminectomy, 5 patients received 1-level unilateral partial laminectomy, 13 received a diskectomy, and 2 received a total laminectomy. This study was approved by the Research Ethics Committee of Osaka Rosai Hospital.
All patients had severe, disabling lower limb pain with or without low back pain unresponsive to conservative treatment. The indications for PLIF were as follows: spondylolisthesis with slippage >3 mm with a posterior opening >5 degrees on flexion radiographs, lumbar spine stenosis with foraminal stenosis of the same segment, or a huge central lumbar disk hernia requiring wide decompression. All PLIF procedures were performed using the same technique described previously.18 Our PLIF procedure included a bilateral total facetectomy, subtotal diskectomy, a large amount of autologous bone graft with 2 carbon cages, and pedicle screw fixation. We believe that a wide surgical field provides
posterolateral fusion; and 2 fusion, 2-levels or more spinal fusion. (*P < 0.05, Mann-Whitney U test, **P < 0.05, analysis of variance with Bonferroni post-hoc test.)
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advantages for installation of a large amount of autologous bone graft and acquisition of a large segmental lordosis. OUTCOME MEASURES The incidence and time periods of multiple-repeated ASD were investigated. To elucidate clinical features of the multiple-repeated ASD, all 4 cases were shown as the case description including radiographic parameters. STATISTICAL ANALYSIS To assess the statistical difference in the incidence and time period between primary PLIF to first ASD and first to second ASD and between first to second ASD and second to third ASD, a Mann-Whitney U test was performed. To assess the statistical difference in the incidence according to surgical procedure, a Mann-Whitney U test was performed in the first ASD and an analysis of variance (ANOVA) using a Bonferroni post-hoc test was
Figure 2. Lateral standing radiographs of the whole spine in Case 1 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). BPL, bilateral partial laminectomy; EBL, estimated blood loss; DS, degenerative spondylolisthesis; F, female; LS,
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performed in the second and third ASD. A P value < 0.05 was considered significant. All statistical analyses were conducted using SPSS Statistics for Windows version 21 (IBM Corp. Chicago, Illinois, USA). RESULTS Incidence and Time Periods of Multiple-Repeated Adjacent Segment Disease After PLIF A total of 116 patients (10.4%) developed the first ASD 5.4 years after the primary PLIF, 14 patients (12.0% of the first ASD patients, 1.3% of the total) developed the second ASD (repeated ASD) 3.3 years after the last surgery, and 4 patients (28.6% of the second ASD patients, 0.4% of the total) developed the third ASD (multiplerepeated ASD) 1.5 years after the last surgery (Figure 1). There were no significant differences in the incidence (P ¼ 0.59, between primary PLIF to first ASD and first to second ASD; P ¼ 0.09 between first to second ASD and second to third ASD) and time
lumbosacral; LSS, lumbar spinal canal stenosis; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; y.o, years old.
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periods (P ¼ 0.12, between primary PLIF to first ASD and first to second ASD; P ¼ 0.12 between first to second ASD and second to third ASD). As for multiple-repeated ASD patients, the first ASD occurred at an average of 3.0 years after the primary PLIF, while in overall, at an average of 5.4 years. In cases with a third ASD, the first ASD tended to occur earlier with no statistical significance (P ¼ 0.27, Case 1, 1.4 years; Case 2, 5.4 years; Case 3, 3.1 years; Case 4, 2.0 years). In terms of ASD by surgical procedures, no difference was detected in the ASD incidence between PLIF alone and PLIF with adjacent segment decompression simultaneously (P ¼ 0.91). Of the 37 first ASD patients who underwent PLIF with adjacent segment decompression simultaneously at primary surgery, 25 patients developed ASD at the adjacent decompression segment, while 12 patients developed ASD at levels other than that of the previous decompression (Figure 1).
Figure 3. Lateral standing radiographs of the whole spine in Case 2 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). BPL, bilateral partial laminectomy; EBL, estimated blood loss; DS, degenerative spondylolisthesis; F, female; LS,
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CASE DESCRIPTION Case 1 Primary Surgery. A 69-year-old woman who had a history of hypertension and insulin-dependent diabetes complained of bilateral lower limb pain and intermittent claudication. Plain radiographs showed L3 DS, and a preoperative myelogram showed an incomplete block at the L2-4 segment. She underwent PLIF at L3-4 and concomitant partial laminectomy at L2-3 (Figure 2A). Clinical Course to Multiple-Repeated Adjacent Segment Disease. Although this patient’s symptoms resolved after primary surgery, de novo L2 DS was observed at 1 year after primary surgery and her neurologic symptoms gradually deteriorated. At 1.4 years after primary surgery, PLIF at L2-3 was performed for the first ASD (Figure 2B). However, canal stenosis with kyphotic deformity at L1-2 appeared and gradually progressed after the
lumbosacral; LSS, lumbar spinal canal stenosis; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; VC, vertebral collapse; VCR, vertebral column resection; y.o, years old.
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second surgery (Figure 2C). Her neurologic symptoms deteriorated again and intractable low back pain emerged. At 5.8 years after the second surgery, PLIF at L1-2 and pedicle subtraction osteotomy (PSO) at L2, with pedicle screw fixation between T4 and L5, was performed for the second ASD. Furthermore, a kyphotic deformity at the lumbosacral junction was observed only 2 months after the last surgery and, again, intractable low back pain was noted. At 5 months after the last surgery, PLIF at L5-S and PSO at L5, with an extension of the pedicle screw fixation to the pelvis using an S2 alar-iliac (S2AI) screw, were performed for the third ASD (Figure 2D). Her symptoms and sagittal imbalance improved. Latest Status. The pedicle screw fixation was extended to T1 due to proximal junctional failure at T3-4 at 9 months after the fourth surgery. However, at 10.0 years after the primary surgery, her global sagittal balance was maintained and she could walk with a cane (Figure 2E).
Figure 4. Lateral standing radiographs of the whole spine in Case 3 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). BPL, bilateral partial laminectomy; DH, disk hernia; EBL, estimated blood loss; DS, degenerative spondylolisthesis;
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Case 2 A 61-year-old woman who had a history of insulin-dependent diabetes underwent PLIF at L4-5 for L4 DS (Figure 3A). Both the first and second ASDs were de novo DS at the upper adjacent segment, and PLIF was performed twice for her recurrent neurologic symptoms at L3-4 (Figure 3B) and L2-3 (Figure 3C). After a stepwise L2-5 fusion, a kyphotic deformity at the proximal junction of the fusion mass was noted as an L1 spontaneous vertebral collapse (Figure 3D). The third ASD was a kyphotic deformity with stenosis at the proximal junctional segment. A vertebral column resection at L1 and replacement of titanium mesh cages with pedicle screw fixation between T4 and L5 were performed for her gait changes, intractable low back pain and fatigue, and recurrent neurologic symptoms. At the latest follow-up (13.8 years after the primary surgery, Figure 3E), her global sagittal imbalance had gradually progressed at the lumbosacral junction. Although her lower-limb pain had
F, female; LS, lumbosacral; LSS, lumbar spinal canal stenosis; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; y.o, years old.
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resolved, she could only walk for 5 minutes with a cart because of low back pain. Corrective surgery was planned but abandoned due to cardiac dysfunction. This patient died of cardiac dysfunction 5 years after the last surgery. Case 3 A 66-year-old woman who had no past medical history underwent PLIF at L4-5 and concomitant partial laminectomy at L3-4 for L4 DS and L3-4 LSS (Figure 4A). The first ASD involved de novo DS at the upper adjacent segment, and PLIF was performed for her recurrent neurologic symptom at L3-4 (Figure 4B). However, her lumbar lordosis decreased as a result of stepwise L3-5 fusion. The second ASD was a large disk herniation at the proximal junction of the fusion mass with low lumbar lordosis (Figure 4C). PLIF at L2-3 and PSO at L3 with pedicle screw fixation between T10 and L6 were performed for her recurrent neurologic symptom. The third ASD was a kyphotic deformity at the lumbosacral junction
Figure 5. Radiographs of Case 4 obtained before the first (A), second (B), third (C), and fourth (D) surgeries, as well as at the final follow-up (E). The films before the first (A) and second (B) surgery were lateral standing radiographs of the lumbar spine during myelography, and the other films were lateral standing radiographs of the whole spine. Before the third surgery (C), no implantation was observed because all implantation was
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because L6-S segment was left mobile (Figure 4D). PLIF at L5-6 and PSO at L6 with an extension of the pedicle screw fixation to the pelvis using an S2AI screw were performed for her intractable low back pain and fatigue. At the latest follow-up (9.5 years after the primary surgery, Figure 4E), her global sagittal balance was maintained. She could walk using a cart without low back pain though residual lower extremity weakness remained. Case 4 A 64-year-old man who had a history of depression underwent PLIF at L4-5 for L4 DS (Figure 5A). The first ASD was a de novo LSS at L2-4 (Figure 5B). A partial laminectomy at L2-4 was performed for his neurologic symptoms. The second ASD was DS at decompression segments (Figure 5C). PLIF at L2-4 was performed for his neurologic symptoms. However, the third ASD was de novo LSS at L1-2 with low lumbar lordosis (Figure 5D). A partial laminectomy at L1-2 with pedicle screw fixation between T9 and
removed at the second surgery. BPL, bilateral partial laminectomy; EBL, estimated blood loss; DS, degenerative spondylolisthesis; F, female; LS, lumbosacral; LSS, lumbar spinal canal stenosis; M, male; Op, operative; PLIF, posterior lumbar interbody fusion; PSF, posterior spinal fusion; PSO, pedicle subtraction osteotomy; y.o, years old.
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Figure 6. Clinical course of the global sagittal alignment. SVA (A), LL (B), PT (C), and PI-LL (D). FU, follow-up; LL, lumbar lordosis; N/A, whole spine images were not
L4 was performed for his neurologic symptoms. However, the additional fusion ended up worsening the postoperative sagittal alignment because the application of the lumbar lordosis was insufficient. At the latest follow-up (15.8 years after the primary surgery, Figure 5E), his global sagittal balance was noted to have deteriorated gradually; nevertheless, he could walk freely without assistance. The clinical course of the global sagittal alignment and the local sagittal alignment after the primary surgery in the 4 cases is shown in Figure 6 and Table 1, respectively. DISCUSSION Frequency and Clinical Features of Repeated Adjacent Segment Disease Several studies have been conducted on the results of reoperation for ASD after lumbar fusion, and 4 of them found that 4.5%12.1% of ASD patients developed repeated ASD.13-17 As for multiple-repeated ASD, Phillips et al16 reported 33 cases of ASD patients who experienced lumbar fusion, four (12.1% of the first ASD patients) had developed a second ASD and in the four, and two (50% of the second ASD patients) developed a third ASD. However, the study lacked description of the population of primary surgery and details of the third ASD cases.16 The present results indicating that 12% of those with a first ASD developed a second ASD and 28.6% of those with a second ASD developed a third ASD were acceptable compared with the previous reports. Patients with 1 reoperation after lumbar surgery are at considerable risk for needing further
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available; PI, pelvic incidence; PT, pelvic tilt; SVA, sagittal vertical axis.
lumbar surgeries.19 Also in ASD cases, the surgical rate had a tendency to increase and the interval between surgeries reduced as the ASD repeated. In addition, the first ASD in the 4 patients who had a third ASD occurred at an average of 3 years after the primary PLIF, while in overall, at an average of 5.4 years. In cases with a third ASD, the first ASD tended to occur earlier. All patients with multiple-repeated ASD complained of neurologic symptoms in the lower limb during the first ASD. However, they developed an iatrogenic flatback as a result of repeated PLIFs for ASD and complained of thoracolumbar symptoms, such as standing and gait disturbance along with intractable low back pain and/or fatigue in addition to neurologic symptoms in the lower limb associated with the second or later ASD. Although the diagnoses and operative treatments were done appropriately at every revision surgery, all of the patients finally
Table 1. Local Sagittal Alignment at Posterior Lumbar Interbody Fusion Level After Primary Operation Intervertebral Level
SL (degrees)
DA (degrees)
Case 1
L3-4
0
4
Case 2
L4-5
9
1
Case 3
L4-5
4
4
Case 4
L4-5
5
0
Both SL and DA were measured at the surgical intervertebral level. SL, segmental lordosis; DA, disk angle.
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required corrective surgery for the iatrogenic flatback in order to achieve sagittal balance and their activities of daily living gradually deteriorated as the surgeries were repeated. Risk Factors for Adjacent Segment Disease Among various reported risk factors of ASD, some studies have reported adjacent segment decompression as the risk factor.20-22 In the present series, no difference was detected in the ASD incidence between PLIF alone and PLIF with adjacent segment decompression simultaneously. Several studies have reported that abnormal sagittal balance and/or parameters could be responsible for ASD after lumbar fusion, and the following factors have been identified: less severe lumbar lordosis,23,24 smaller sacral slope,25,26 greater pelvic tilt,24,25 greater sagittal vertical axis,24 greater pelvic incidence,9 and greater pelvic incidencelumbar lordosis (PI-LL).24,27,28 In the present series, all patients lost their lumbar lordosis and subsequently developed iatrogenic flatback as ASD was repeated, as shown in Figure 6AeD. Among sagittal parameters, only segmental lordosis could be managed during the PLIF procedures. Kim et al29 showed that a low postoperative segmental lordosis at L4-5, in particular <20 degrees, at the index level was related to the development of clinical ASD. We also performed a risk factor analysis for ASD regarding spinopelvic parameters and concluded that postoperative PI-LL was a major risk factor for ASD and postoperative lumbar lordosis was correlated with segmental lordosis at the fused segment.24 In the current 4 patients, segmental lordosis and disk angle at the primary PLIF appeared to be insufficient, ranging from 0 to 9 degrees and 4 to 1 degree (see Table 1). From previous reports and the present results, surgeons should endeavor to achieve adequate segmental lordosis using techniques, such as the forward installation of a bone graft with cages, use of hyper wedge cages, and compression.24,29 Even when ASD occurs, adequate segmental lordosis at the first surgery could reduce the invasion of salvage surgery. Treatment Strategies for Adjacent Segment Disease When PLIF was repeated for ASD, most cases demonstrated reduced lumbar lordosis and, subsequently, their global sagittal balance deteriorated along with compensatory thoracic hypokyphosis and pelvis retroversion. In such cases, global alignment should be evaluated as adult spine deformity, in addition to the
REFERENCES 1. Okuda S, Miyauchi A, Oda T, Haku T, Yamamoto T, Iwasaki M. Surgical complications of posterior lumbar interbody fusion with total facetectomy in 251 patients. J Neurosurg Spine. 2006; 4:304-309. 2. Okuda S, Oda T, Miyauchi A, Haku T, Yamamoto T, Iwasaki M. Surgical outcomes of posterior lumbar interbody fusion in elderly patients. J Bone Joint Surg Am. 2006;88:2714-2720. 3. Trouillier H, Birkenmaier C, Rauch A, Weiler C, Kauschke T, Refior HJ. Posterior lumbar interbody fusion (PLIF) with cages and local bone graft in the treatment of spinal stenosis. Acta Orthop Belg. 2006;72:460-466.
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degree of stenosis and instability. Regarding the surgical strategy for a first ASD, if additional PLIF is required, segmental lordosis should be achieved in the aforementioned manner. However, regarding a second or later ASD, corrective surgery should be considered rather than a repeat PLIF for adult spine deformity. With respect to corrective surgery for multiple-repeated ASD, total lumbar fusion to the pelvis appears to have some advantages for the following reasons. First, it is difficult to achieve adequate lumbar lordosis only by lumbar corrective fusion in patients who demonstrate multisegment lumbar fusion. Second, lumbosacral fusion can achieve the correction of compensatory pelvic retroversion. In the present series, the lower instrumented vertebrae of all 4 cases in corrective surgery were the most caudal lumbar vertebrae (L5 or L6). However, 2 patients experienced a rapid deterioration of kyphosis at the lumbosacral junction and complained of standing disturbance with severe low back pain. These 2 patients required an extension of the fixation to the pelvis using an S2AI screw and maintained an adequate sagittal balance at the final follow-up. Limitations First, given the inherent limitation of a 4-patient case report, this study lacked statistical data and risk factors for multiple-repeated ASD could not be elucidated in this study. Second, there was a wide range in the time to follow-up (0.5e21.1 years). The ASD rate and time period would change by the follow-up period, as mentioned earlier. However, the mean follow-up period of 6.4 years and rate of 55.4% were acceptable in such a large and longterm follow-up study.
CONCLUSION We reported 4 cases of multiple-repeated ASD after PLIF, with an incidence of 0.4% over 2 decades. All patients showed insufficient segmental lordosis and disk angle at the primary PLIF and developed iatrogenic flatback due to repeated ASD. Moreover, all patients required thoracolumbar or spinopelvic corrective surgeries. Although the incidence is very low to date, multiplerepeated ASD may become important as the number of affected patients is expected to increase because of increased follow-up periods.
4. Yamamoto T, Ohkohchi T, Ohwada T, Kotoku H, Harada N. Clinical and radiological results of PLIF for degenerative spondylolisthesis. J Musculoskel Res. 1998;2:181-195. 5. Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG. Adjacent segment degeneration in the lumbar spine. JBJS. 2004;86:1497-1503. 6. Heo Y, Park JH, Seong HY, Lee Y-S, Jeon SR, Rhim SC, et al. Symptomatic adjacent segment degeneration at the L3e4 level after fusion surgery at the L4e5 level: evaluation of the risk factors and 10-year incidence. Eur Spine J. 2015;24: 2474-2480. 7. Lee CS, Hwang CJ, Lee S-W, Ahn Y-J, Kim Y-T, Lee D-H, et al. Risk factors for adjacent segment
disease after lumbar fusion. Eur Spine J. 2009;18: 1637. 8. Lee JC, Kim Y, Soh J-W, Shin B-J. Risk factors of adjacent segment disease requiring surgery after lumbar spinal fusion: comparison of posterior lumbar interbody fusion and posterolateral fusion. Spine. 2014;39:E339-E345. 9. Nakashima H, Kawakami N, Tsuji T, Ohara T, Suzuki Y, Saito T, et al. Adjacent segment disease after posterior lumbar interbody fusion: based on cases with a minimum of 10 years of follow-up. Spine. 2015;40:E831-E841. 10. Okuda S, Fujimori T, Oda T, Yamasaki R, Maeno T, Yamashita T, et al. Patient-based surgical outcomes of posterior lumbar interbody
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fusion: patient satisfaction analysis. Spine (Phila Pa 1976). 2016;41:E148-154. 11. Okuda S, Oda T, Yamasaki R, Haku T, Maeno T, Iwasaki M. Posterior lumbar interbody fusion with total facetectomy for low-dysplastic isthmic spondylolisthesis: effects of slip reduction on surgical outcomes: clinical article. J Neurosurg Spine. 2014;21:171-178. 12. Sears WR, Sergides IG, Kazemi N, Smith M, White GJ, Osburg B. Incidence and prevalence of surgery at segments adjacent to a previous posterior lumbar arthrodesis. Spine J. 2011;11:11-20.
posterior lumbar interbody fusion in elderly patients. Surgical technique. J Bone Joint Surg Am. 2007;89(suppl 2):310-320. 19. Österman H, Sund R, Seitsalo S, Keskimäki I. Risk of multiple reoperations after lumbar discectomy: a population-based study. Spine. 2003;28: 621-627. 20. Ekman P, Möller H, Shalabi A, Yu YX, Hedlund R. A prospective randomised study on the long-term effect of lumbar fusion on adjacent disc degeneration. Eur Spine J. 2009;18:1175-1186.
patients undergoing revision surgery. Eur Spine J. 2014;23:693-698. 26. Kumar M, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J. 2001;10:314-319. 27. Rothenfluh DA, Mueller DA, Rothenfluh E, Min K. Pelvic incidence-lumbar lordosis mismatch predisposes to adjacent segment disease after lumbar spinal fusion. Eur Spine J. 2015; 24:1251-1258.
13. Chen W-J, Lai P-L, Niu C-C, Chen L-H, Fu T-S, Wong C-B. Surgical treatment of adjacent instability after lumbar spine fusion. Spine. 2001;26: E519-E524.
21. Lai P-L, Chen L-H, Niu C-C, Fu T-S, Chen W-J. Relation between laminectomy and development of adjacent segment instability after lumbar fusion with pedicle fixation. Spine. 2004;29:2527-2532.
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Conflict of interest statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Received 22 July 2018; accepted 28 September 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.09.227 Journal homepage: www.WORLDNEUROSURGERY.org
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