Comparison of long fusion terminating at L5 versus the sacrum in treating adult spinal deformity: a meta-analysis

Fei Jia,Guodong Wang,Xiaoyang Liu,Tao Li,Jianmin Sun

doi:10.1007/s00586-019-06187-8

Abstract

PurposeChoosing an optimal distal fusion level for adult spinal deformity (ASD) is still controversial. To compare the radiographic and clinical outcomes of distal fusion to L5 versus the sacrum in ASD, we conducted a meta-analysis.MethodsRelevant studies on long fusion terminating at L5 or the sacrum in ASD were retrieved from the PubMed, Embase, Cochrane, and Google Scholar databases. Then, studies were manually selected for inclusion based on predefined criteria. The meta-analysis was performed by RevMan 5.3.ResultsEleven retrospective studies with 1211 patients were included in meta-analysis. No significant difference was found in overall complication rate (95% CI 0.60 to 1.30) and revision rate (95% CI 0.59 to 1.99) between fusion to L5 group (L group) and fusion to the sacrum group (S group). Significant lower rate of pseudarthrosis and implant-related complications (95% CI 0.29 to 0.64) as well as proximal adjacent segment disease (95% CI 0.35 to 0.92) was found in L group. Patients in S group obtained a better correction of lumbar lordosis (95% CI − 7.85 to − 0.38) and less loss of sagittal balance (95% CI − 1.80 to − 0.50).ConclusionOur meta-analysis suggested that long fusion terminating at L5 or the sacrum was similar in scoliosis correction, overall complication rate, revision rate, and improvement in pain and disability. However, fusion to L5 had advantages in lower rate of pseudarthrosis, implant-related complications, and proximal adjacent segment disease, while fusion to the sacrum had advantages in the restoration of lumbar lordosis, maintenance of sagittal balance, and absence of distal adjacent segment disease.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Highlights

Adult spinal deformity is a common disease with a reported incidence ranging from 29 to 68% [1, 2]
Studies were included according to the following inclusion criteria: (1) patients were diagnosed with adult spinal deformity; (2) patients with at least 18 years of age at the time of surgery; (3) fusion of four or more segments; (4) patients with healthy or minimal degenerated L5-S1 discs (Grade 0 to 1); (5) availability of comparative data of distal fusion level between L5 and the sacrum; and (6) a minimum 1-year follow-up
Studies were excluded according to the following exclusion criteria: (1) patients were diagnosed with neuromuscular scoliosis; (2) child or adolescent patients; (3) patients were treated by short fusion or non-fusion procedure; (4) pooled results were reported without distinguishing endpoint L5 from the sacrum; (5) the article was a case/case series report; and (6) biomechanical study or studies of corpses

Summary

Introduction

Adult spinal deformity is a common disease with a reported incidence ranging from 29 to 68% [1, 2]. Adult patients with spinal deformity can present with back pain, symptoms of nerve compression, and impaired quality of life [3–6]. The goal of surgery is to achieve neural decompression, correct the deformity, and restore the balance of spine in both coronal and sagittal planes. Achieving these goals can be challenging and cause various complications such as wound infection, neurological impairment, pseudarthrosis, and adjacent segment disease [9–13]. Patients are older and may have some medical comorbidities [15]. These factors contribute to the high incidence of complications

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