Frequency, risk factors, and treatment of distal adjacent segment pathology after long thoracolumbar fusion: a systematic review.

Published

Journal Article

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review the literature related to distal adjacent segment pathology (ASP) after long thoracolumbar fusions for deformity including frequency, risk factors, frequency differences between adolescents and adults, surgical approach for revision, and revision complications. SUMMARY OF BACKGROUND DATA: Spinal deformity surgery complications include ASP. Although ASP at the rostral end of instrumented fusions has been well described, substantially less has been documented about distal ASP. METHODS: A systematic search was conducted in Medline and the Cochrane Collaboration Library for articles published between January 1, 1983, and March 15, 2012. We included all articles that described distal ASP after long thoracolumbar fusion for deformity. Radiographical ASP (RASP) was defined as evidence of ASP based on imaging, and clinical ASP (CASP) was defined as symptomatic ASP. RESULTS: Seven retrospective cohort studies met inclusion criteria. Distal CASP developed in 17.7% at 2- 6-year follow-up and 19.8% at 9-year follow-up, whereas reoperation due to CASP was reported in 15.6% at 2 to 6 years and 14.4% at 9 years. Distal RASP was more frequent (44.7%-65.5%). Preoperative sagittal imbalance was associated with increased risk of distal ASP. There was increased risk of CASP in patients with higher postoperative fractional curve and increased risk of RASP in younger patients and those with preoperative disc degeneration, longer fusions, circumferential procedures, and postoperative L5-S1 disc space narrowing. No studies meeting inclusion criteria compared distal ASP in adults and adolescents or defined the best approach or complications for distal ASP revision. CONCLUSION: Low-quality evidence suggests a cumulative rate of 18% to 20% for CASP and 45% to 65% for RASP after long thoracolumbar fusion for spinal deformity during 9-year follow-up. Low-quality evidence suggests an association between preoperative sagittal imbalance and distal ASP, with greater risk of distal ASP in patients with sagittal imbalance. Low-quality evidence suggests increased risk of CASP in patients with higher postoperative fractional curve and increased risk of RASP in younger patients and those with preoperative disc degeneration, longer fusions, circumferential procedures, and postoperative L5-S1 disc space narrowing. CONSENSUS STATEMENT: 1. The risk of developing new symptoms secondary to distal adjacent segment pathology following long thoracolumbar fusion for deformity is approximately 18–20% during a period of 9 years follow up, and most of these patients will require revision surgery. Strength of Statement: Weak. 2. The risk of developing distal adjacent segment pathology may be higher in those with preoperative sagittal imbalance, preoperative disc degeneration, longer fusions, circumferential procedures, and postoperative L5–S1 disc space narrowing. Strength of Statement: Weak.

Full Text

Duke Authors

Cited Authors

  • Kasliwal, MK; Shaffrey, CI; Lenke, LG; Dettori, JR; Ely, CG; Smith, JS

Published Date

  • October 15, 2012

Published In

Volume / Issue

  • 37 / 22 Suppl

Start / End Page

  • S165 - S179

PubMed ID

  • 22885833

Pubmed Central ID

  • 22885833

Electronic International Standard Serial Number (EISSN)

  • 1528-1159

Digital Object Identifier (DOI)

  • 10.1097/BRS.0b013e31826d62c9

Language

  • eng

Conference Location

  • United States