Musculoskeletal biomechanics of patients with or without adjacent segment degeneration after spinal fusion

Abstract Study design A retrospective, single center, case-control study was performed. Objective The present study employed patient-specific biomechanical modeling to find potential biomechanical differences after spinal fusion at L4/5 in patients with and without subsequent development of adjacent segment disease (ASD). Methods The study population comprised patients who underwent primary spinal fusion at L4/5 and were either asymptomatic during > 4 years of follow-up (CTRL; n = 18) or underwent revision surgery for ASD at L3/4 (n = 20). Landmarks were annotated on preoperative and follow-up lateral radiographs, and specific musculoskeletal models were created using a custom-built modeling pipeline. Simulated spinal muscle activation and lumbar intervertebral shear loads in unfused segments were analyzed in upright standing and forward flexion. Differences between the pre- and postoperative conditions were computed for each patient. Results The average postoperative muscle activity in the upright standing posture was 88.4% of the preoperative activity in the CTRL group (p < 0.0001), but did not significantly change from pre- to postoperatively in the ASD group (98.0%). The average shear load magnitude at the epifusional joint L3/4 during upright standing increased from pre- to postoperatively in the ASD group (+ 3.9 N, +/− 17.4 (n = 18)), but decreased in the CTRL group (− 4.6 N, +/− 23.3 (n = 20); p < 0.001). Conclusion Patient-specific biomechanical simulation revealed that spinal fusion surgery resulted in greater shear load magnitude and muscle activation and therefore greater forces at the epifusional segment in those with ASD compared with those without ASD. This is a first report of patient-specific disc load and muscle force calculation with predictive merits for ASD.

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Comparison of patient-specific computational models vs. clinical follow-up, for adjacent segment disc degeneration and bone remodelling after spinal fusion

PLoS ONE ◽

10.1371/journal.pone.0200899 ◽

2018 ◽

Vol 13 (8) ◽

pp. e0200899 ◽

Cited By ~ 6

Author(s):

Marc van Rijsbergen ◽

Bert van Rietbergen ◽

Veronique Barthelemy ◽

Peter Eltes ◽

Áron Lazáry ◽

...

Keyword(s):

Spinal Fusion ◽

Disc Degeneration ◽

Computational Models ◽

Bone Remodelling ◽

Patient Specific ◽

Adjacent Segment

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Predicting factors of adjacent segment degeneration after long-segment spinal fusion: spinopelvic parameters analysis

10.21203/rs.2.18590/v2 ◽

2020 ◽

Author(s):

Ping-Yeh Chiu ◽

Fu-Cheng Kao ◽

Wen-Jer Chen ◽

Chia-Wei Yu ◽

Chi-Chien Niu ◽

...

Keyword(s):

Spinal Fusion ◽

Lumbar Fusion ◽

Adjacent Segment Degeneration ◽

Control Group ◽

Sacral Slope ◽

Adjacent Segment ◽

Spinopelvic Parameters ◽

Significant Difference ◽

Adjacent Disc

Abstract Background We investigated whether spinopelvic parameters are important prognostic factors causing adjacent segment degeneration (ASD) after long instrumented spinal fusion for degenerative spinal disease. Methods This uncontrolled, randomized, single arm retrospective study included patients who underwent long instrumented lumbar fusion (fusion levels≥ 4) in the past 5 years with follow-up for at least 2 years. The inclusion criteria included adult patients (≥40 years of age) with a diagnosis of spinal degeneration who underwent instrumented corrective surgery. The exclusion criteria included preexisting adjacent disc degeneration, combined anterior reconstructive surgery, and distal ASD. Clinical and operative characters were evaluated. Angle of lumbar lordosis (LLA), sacral slope (SSA), pelvic tilt (PTA) and pelvic incidence (PIA) were compared preoperatively, postoperatively and at the final follow-up. Results From 2009 to 2014, 60 patients (30 ASD and 30 non-ASD) were enrolled. The average age was 66.82 ± 7.48 years for the study group and 67.97 ± 7.81 years for the control group. There was no statistically significant difference in clinical and operative characteristics. Among all spinopelvic parameters, only pre-, post-operative and final follow-up PIA in ASD group (53.9±10.4ﾟ, 54.6±14.0ﾟ, 54.3±14.1ﾟ) and non-ASD group (60.3±13.0ﾟ, 61.8±11.3ﾟ, 62.5±11.2ﾟ) showed statistically significant differences ( p <0.05). Conclusion This study confirms that preoperative, postoperative and final follow-up PIA is a significant factor contributing to the development of ASD after long instrumented spinal fusion.

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EFFECTS ON ADJACENT SEGMENT AFTER MINIMUM FIVE-YEARS FOLLOWING INSTRUMENTED LUMBAR SPINAL FUSION IN INDIAN POPULATION

10.36106/gjra/6811205 ◽

2020 ◽

pp. 132-135

Author(s):

Yogesh Kishorkant Pithwa

Keyword(s):

Spinal Fusion ◽

Lumbar Lordosis ◽

Indian Population ◽

Lower Limbs ◽

Walking Distance ◽

Adjacent Segment ◽

Lumbar Spinal Fusion ◽

Time Of Surgery ◽

Lumbar Spinal

Adjacent segment degeneration [ASD] after instrumented lumbar spinal fusion has been studied extensively in non-Indian population. Present study attempts to evaluate incidence of and factors predisposing to ASD in the Indian population. This was a retrospective study with the inclusion criteria being: patients who underwent lumbar spinal fusion for spondylolisthesis, trauma, infection or deformity with a minimum five-year follow-up. Exclusion criteria: postoperative iatrogenic surgical-site infections, revision surgeries, postoperative implant failure and pseudarthrosis. Radiographs reviewed immediate postoperatively, and at final follow-up. Global lumbar lordosis from L1-S1; and angulation and translation of spinal motion segment immediately adjacent [cranial and caudal] to fused segment were studied. ASD was defined using White and Panjabi’s criteria. At final follow-up, VAS for lower back as well as lower limbs was noted separately along with walking distance. Twenty patients [49.4+17.4years] included [six males, fourteen females]. ASD was seen in 13 of 20 [65%] patients. Age>50years at the time of surgery and global lumbar lordosis <40° in the immediate postoperative period were identified as significant risk factors for ASD [p=0.02 and 0.03, respectively]. However, no significant correlation was noted between development of ASD and extension of fusion to sacrum. Nor was there any correlation between ASD and gender or length of fusion. It was also notable that no significant differences were identified in VAS scores and walking distance between patients with and without ASD. To conclude, among the various factors studied, age>50years at the time of surgery and immediate postoperative global lumbar lordosis <400 were significantly associated with development of ASD after a minimum follow-up of five years.

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Treatment of adjacent segment disease with percutaneous transforaminal endoscopic discectomy: Early experience and results

Journal of Orthopaedic Surgery ◽

10.1177/2309499020960560 ◽

2020 ◽

Vol 28 (3) ◽

pp. 230949902096056

Author(s):

Stylianos Kapetanakis ◽

Nikolaos Gkantsinikoudis ◽

Grigorios Gkasdaris ◽

Georgios Charitoudis

Keyword(s):

Spinal Fusion ◽

Short Form ◽

Bodily Pain ◽

Adjacent Segment Disease ◽

Adjacent Segment ◽

Significant Differentiation ◽

Sf 36 ◽

Endoscopic Discectomy ◽

Percutaneous Transforaminal Endoscopic Discectomy

Purpose: Adjacent segment disease (ASD) constitutes a long-term complication of instrumented spinal fusion. Aim of this study is to analyze the utilization of percutaneous transforaminal endoscopic discectomy (PTED) for the treatment of symptomatic ASD, emphasizing basically in the postoperative course. Methods: A prospective study with 35 patients was designed. Patients enrolled in our study were distributed in two different groups. Group A constituted of 15 patients featuring ASD as a complication of a previously conducted lumbar spinal fusion. Group B was composed of 20 patients, presenting simple lumbar disc herniation (LDH). All patients were subjected to successful PTED for LDH. Patients were evaluated at regular intervals in 6-week and 3-, 6-, and 12-month postoperatively. Visual analog scale was utilized for leg (VAS-LP) and low back pain (VAS-BP) evaluation. Health-related quality of life was assessed with short-form 36 health survey questionnaire (SF-36). Results: VAS-BP scores were statistically significantly differentiated between the two groups in all intervals of follow-up. In contrast, VAS-LP scores demonstrated statistically significant differentiation in none of follow-up intervals, indicating similar results between the two groups. Maximal improvement was in both cases for all patients observed in 6-week postoperatively, with subsequent stabilization. SF-36 preoperative evaluation denoted a statistically significant differentiation in bodily pain and role emotional parameters, which was continually until the end of follow-up observed. The other SF-36 parameters featured similar values between the two groups preoperatively as well as during the follow-up intervals. Conclusion: PTED is capable of successfully dealing with LDH and furthermore with complications of fusion as ASD.

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Predicting factors of adjacent segment degeneration after long-segment spinal fusion: spinopelvic parameters analysis

10.21203/rs.2.18590/v1 ◽

2019 ◽

Author(s):

Ping-Yeh Chiu ◽

Fu-Cheng Kao ◽

Wen-Jer Chen ◽

Chia-Wei Yu ◽

Chi-Chien Niu ◽

...

Keyword(s):

Spinal Fusion ◽

Lumbar Fusion ◽

Slope Angle ◽

Adjacent Segment Degeneration ◽

Control Group ◽

Adjacent Segment ◽

Spinopelvic Parameters ◽

Significant Difference ◽

Adjacent Disc

Abstract Purpose We investigated whether spinopelvic parameters are important prognostic factors for adjacent segment degeneration after long instrumented spinal fusion for degenerative spinal disease. Methods This uncontrolled, randomized, single arm retrospective study included patients who underwent long instrumented lumbar fusion (fusion levels≥ 4) in the past 5 years with follow-up for at least 2 years. The inclusion criteria included adult patients (≥40 years of age) with a diagnosis of spinal degeneration who underwent instrumented corrective surgery. The exclusion criteria included preexisting adjacent disc degeneration, combined anterior reconstructive surgery, and distal ASD. Clinical and operative characters were evaluated. Lumbar lordotic angle (LLA), sacral slope angle (SSA), pelvic tilt angle (PTA) and pelvic incidence angle (PIA) were compared preoperatively, postoperatively and at the final follow-up. Results From 2009 to 2014, 60 patients (30 ASD and 30 non-ASD patients) were enrolled. The average age was 66.82 ± 7.48 years for the study group and 67.97 ± 7.81 years for the control group. There was no statistically significant difference in clinical and operative characteristics. Among all spinopelvic parameters, only pre-, post-operative and final follow-up PIA in ASD group (53.9±10.4ﾟ, 54.6±14.0ﾟ, 54.3±14.1ﾟ) and non-ASD group (60.3±13.0ﾟ, 61.8±11.3ﾟ, 62.5±11.2ﾟ) showed statistically significant differences (p<0.05). Conclusion This study confirms that preoperative, postoperative and final follow-up PIA is a significant factor contributing to the development of adjacent segment degeneration after long instrumented spinal fusion.

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Long-Term Residual-Mobility and Adjacent Segment Disease After Total Lumbar Disc Replacement

Global Spine Journal ◽

10.1177/2192568220935813 ◽

2020 ◽

pp. 219256822093581

Author(s):

Joep Kitzen ◽

Timon F. G. Vercoulen ◽

Martijn G. M. Schotanus ◽

Sander M. J. van Kuijk ◽

Nanne P. Kort ◽

...

Keyword(s):

Clinical Outcome ◽

Spinal Fusion ◽

Adjacent Segment Disease ◽

Disc Replacement ◽

Adjacent Segment ◽

Segmental Motion ◽

Flexion Extension ◽

Patient Reported

Study Design: Retrospective cohort study. Objectives: Total disc replacement (TDR) has been introduced in order to preserve segmental motion and thus reduce adjacent segment disease (ASD) as seen after spinal fusion. However, it is uncertain whether these presumed beneficial effects remain. The aim of this study was to evaluate the long-term incidence of ASD and residual-mobility in relation to clinical outcome. Methods: A total of 210 patients treated with lumbar TDR for degenerative disc disease were invited for follow-up. ASD was reported in case of severe degeneration in an adjacent disc at latest follow-up, or if an increase in disc degeneration was observed in these adjacent segments as compared to direct postoperative radiographs. Residual-mobility of the TDR was defined as a minimal rotation of 4.6° on flexion-extension radiographs. Patient-reported outcome measures were obtained. Results: Fifty-seven patients (27.1%) were lost to follow-up. In 32 patients (15.3%) a revision by spinal fusion had been performed. In 20 patients this revision had occurred ≥5 years after TDR and were included. Consequently, 141 patients were available for analysis (mean follow-up of 16.7 years). Residual-mobility was noted in 38.0%. No significant associations were observed between residual-mobility and the occurrence of ASD, or with clinical outcome. In addition, ASD and clinical outcome were not related either. Conclusions: It appears that long-term preservation of motion after TDR is met for only a third of patients. However, residual-mobility is not associated with the occurrence of ASD, and both residual-mobility and ASD do not appear to be related to long-term clinical outcome.

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Severe Head Injury linked to Subsequent Development of Malignant Brain Tumour within a Short Period- A Case Report

Medical & Clinical Research ◽

10.33140/mcr.03.02.09 ◽

2018 ◽

Vol 3 (2) ◽

Keyword(s):

Head Injury ◽

Brain Tumour ◽

Severe Head Injury ◽

Case Reports ◽

Subsequent Development ◽

Malignant Brain Tumour ◽

Tumour Development ◽

Short Period ◽

The Brain

There have been a few case reports of head injury leading to brain tumour development in the same region as the brain injury. Here we report a case where the patient suffered a severe head injury with contusion. He recovered clinically with conservative management. Follow up Computed Tomography scan of the brain a month later showed complete resolution of the lesion. He subsequently developed malignant brain tumour in the same region as the original contusion within a very short period of 15 months. Head injury patients need close follow up especially when severe. The link between severity of head injury and malignant brain tumour development needs further evaluation. Role of anti-inflammatory agents for prevention of post traumatic brain tumours needs further exploration.

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Topping-off technique for stabilization of lumbar degenerative instabilities in 322 patients

Journal of Neurosurgery Spine ◽

10.3171/2019.8.spine181434 ◽

2020 ◽

Vol 32 (3) ◽

pp. 366-372

Author(s):

Sandro M. Krieg ◽

Nele Balser ◽

Haiko Pape ◽

Nico Sollmann ◽

Lucia Albers ◽

...

Keyword(s):

Patient Satisfaction ◽

Interbody Fusion ◽

Smooth Transition ◽

Lumbar Pain ◽

Adjacent Segment ◽

Lumbar Interbody Fusion ◽

Rod System ◽

Reoperation Rates ◽

Topping Off

OBJECTIVESemi-rigid instrumentation (SRI) was introduced to take advantage of the concept of load sharing in surgery for spinal stabilization. The authors investigated a topping-off technique in which interbody fusion is not performed in the uppermost motion segment, thus creating a smooth transition from stabilized to free motion segments. SRI using the topping-off technique also reduces the motion of the adjacent segments, which may reduce the risk of adjacent segment disease (ASD), a frequently observed sequela of instrumentation and fusion, but this technique may also increase the possibility of screw loosening (SL). In the present study the authors aimed to systematically evaluate reoperation rates, clinical outcomes, and potential risk factors and incidences of ASD and SL for this novel approach.METHODSThe authors collected data for the first 322 patients enrolled at their institution from 2009 to 2015 who underwent surgery performed using the topping-off technique. Reoperation rates, patient satisfaction, and other outcome measures were evaluated. All patients underwent pedicle screw–based semi-rigid stabilization of the lumbar spine with a polyetheretherketone (PEEK) rod system.RESULTSImplantation of PEEK rods during revision surgery was performed in 59.9% of patients. A median of 3 motion segments (range 1–5 segments) were included and a median of 2 motion segments (range 0–4 segments) were fused. A total of 89.4% of patients underwent fusion, 73.3% by transforaminal lumbar interbody fusion (TLIF), 18.4% by anterior lumbar interbody fusion (ALIF), 3.1% by extreme lateral interbody fusion (XLIF), 0.3% by oblique lumbar interbody fusion (OLIF), and 4.9% by combined approaches in the same surgery. Combined radicular and lumbar pain according to a visual analog scale was reduced from 7.9 ± 1.0 to 4.0 ± 3.1, with 56.2% of patients indicating benefit from surgery. After maximum follow-up (4.3 ± 1.8 years), the reoperation rate was 16.4%.CONCLUSIONSThe PEEK rod concept including the topping-off principle seems safe, with at least average patient satisfaction in this patient group. Considering the low rate of first-tier surgeries, the presented results seem at least comparable to those of most other series. Follow-up studies are needed to determine long-term outcomes, particularly with respect to ASD, which might be reduced by the presented approach.

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Obesity may be associated with adjacent-segment degeneration after single-level transforaminal lumbar interbody fusion in spinopelvic-mismatched patients with a minimum 2-year follow-up

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20159 ◽

2021 ◽

Vol 34 (1) ◽

pp. 83-88

Author(s):

Ping-Guo Duan ◽

Praveen V. Mummaneni ◽

Minghao Wang ◽

Andrew K. Chan ◽

Bo Li ◽

...

Keyword(s):

Interbody Fusion ◽

Transforaminal Lumbar Interbody Fusion ◽

Adjacent Segment Degeneration ◽

Adjacent Segment ◽

Lumbar Interbody Fusion ◽

Inclusion Criteria ◽

Single Level ◽

Degenerative Lumbar Spondylolisthesis ◽

Surgery Rates

OBJECTIVEIn this study, the authors’ aim was to investigate whether obesity affects surgery rates for adjacent-segment degeneration (ASD) after transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis.METHODSPatients who underwent single-level TLIF for spondylolisthesis at the University of California, San Francisco, from 2006 to 2016 were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, single-level TLIF, and degenerative lumbar spondylolisthesis. Exclusion criteria were trauma, tumor, infection, multilevel fusions, non-TLIF fusions, or less than a 2-year follow-up. Patient demographic data were collected, and an analysis of spinopelvic parameters was performed. The patients were divided into two groups: mismatched, or pelvic incidence (PI) minus lumbar lordosis (LL) ≥ 10°; and balanced, or PI-LL < 10°. Within the two groups, the patients were further classified by BMI (< 30 and ≥ 30 kg/m2). Patients were then evaluated for surgery for ASD, matched by BMI and PI-LL parameters.RESULTSA total of 190 patients met inclusion criteria (72 males and 118 females, mean age 59.57 ± 12.39 years). The average follow-up was 40.21 ± 20.42 months (range 24–135 months). In total, 24 patients (12.63% of 190) underwent surgery for ASD. Within the entire cohort, 82 patients were in the mismatched group, and 108 patients were in the balanced group. Within the mismatched group, adjacent-segment surgeries occurred at the following rates: BMI < 30 kg/m2, 2.1% (1/48); and BMI ≥ 30 kg/m2, 17.6% (6/34). Significant differences were seen between patients with BMI ≥ 30 and BMI < 30 (p = 0.018). A receiver operating characteristic curve for BMI as a predictor for ASD was established, with an AUC of 0.69 (95% CI 0.49–0.90). The optimal BMI cutoff value determined by the Youden index is 29.95 (sensitivity 0.857; specificity 0.627). However, in the balanced PI-LL group (108/190 patients), there was no difference in surgery rates for ASD among the patients with different BMIs (p > 0.05).CONCLUSIONSIn patients who have a PI-LL mismatch, obesity may be associated with an increased risk of surgery for ASD after TLIF, but in obese patients without PI-LL mismatch, this association was not observed.

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Risk Factors for Failure in Conservatively Treated Osteoporotic Vertebral Fractures: A Systematic Review

Global Spine Journal ◽

10.1177/2192568220982279 ◽

2021 ◽

pp. 219256822098227

Author(s):

Max J. Scheyerer ◽

Ulrich J. A. Spiegl ◽

Sebastian Grueninger ◽

Frank Hartmann ◽

Sebastian Katscher ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Treatment Failure ◽

Patient Specific ◽

Mineral Density ◽

Radiographic Findings ◽

Specific Risk ◽

Fracture Development ◽

Predict Treatment Failure

Study Design: Systematic review. Objectives: Osteoporosis is one of the most common diseases of the elderly, whereby vertebral body fractures are in many cases the first manifestation. Even today, the consequences for patients are underestimated. Therefore, early identification of therapy failures is essential. In this context, the aim of the present systematic review was to evaluate the current literature with respect to clinical and radiographic findings that might predict treatment failure. Methods: We conducted a comprehensive, systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist and algorithm. Results: After the literature search, 724 potentially eligible investigations were identified. In total, 24 studies with 3044 participants and a mean follow-up of 11 months (range 6-27.5 months) were included. Patient-specific risk factors were age >73 years, bone mineral density with a t-score <−2.95, BMI >23 and a modified frailty index >2.5. The following radiological and fracture-specific risk factors could be identified: involvement of the posterior wall, initial height loss, midportion type fracture, development of an intravertebral cleft, fracture at the thoracolumbar junction, fracture involvement of both endplates, different morphological types of fractures, and specific MRI findings. Further, a correlation between sagittal spinal imbalance and treatment failure could be demonstrated. Conclusion: In conclusion, this systematic review identified various factors that predict treatment failure in conservatively treated osteoporotic fractures. In these cases, additional treatment options and surgical treatment strategies should be considered in addition to follow-up examinations.

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