Abstract
Introduction: The development of adjacent-segment disease is a recognized consequence of lumbar fusion surgery. Posterior dynamic stabilization, or motion preservation, techniques have been developed which theoretically decrease stress on adjacent segments following fusion. This study presents the experience of using a hybrid dynamic stabilization and fusion construct for degenerative lumbar spine pathology in place of rigid arthrodesis.Methods: A clinical cohort investigation was conducted of 66 consecutive patients (31 female, 35 male; mean age: 53 years, range: 25 – 76 years) who underwent posterior lumbar instrumentation with the Dynesys Transition Optima (DTO) implant (Zimmer-Biomet Spine, Warsaw, IN) hybrid dynamic stabilization and fusion system over a 10-year period. The median length of follow-up was five years. DTO consists of pedicle screw fixation coupled to a rigid rod as well as a flexible longitudinal connecting system. All patients had symptoms of back pain and neurogenic claudication refractory to non-surgical treatment. Patients underwent lumbar arthrodesis surgery in which the hybrid system was used for stabilization instead of arthrodesis of the stenotic adjacent level.Results: Indications for DTO instrumentation were primary degenerative disc disease (n = 52) and failed back surgery syndrome (n = 14). The most common dynamically stabilized and fused segments were L3-L4 (n = 37) and L5-S1 (n = 33), respectively. Thirty-eight patients (56%) underwent decompression at the dynamically stabilized level, and 57 patients (86%) had an interbody device placed at the level of arthrodesis. Complications during the follow-up period included a single case of screw breakage and a single case of pseudoarthrosis. Ten patients (15%) subsequently underwent conversion of the dynamic stabilization portion of their DTO instrumentation to rigid spinal arthrodesis.Conclusion: The DTO system represents a novel hybrid dynamic stabilization and fusion construct. This 10-year experience found the device to be highly effective as well as safe. The technique may serve as an alternative to multilevel arthrodesis. Implantation of a motion-preserving dynamic stabilization device immediately adjacent to a fused level instead of extending a rigid construct may reduce the subsequent development of adjacent-segment disease in this patient population.
Highlights
The development of adjacent-segment disease is a recognized consequence of lumbar fusion surgery
Arthrodesis has been commonly utilized for symptomatic degenerative conditions of the lumbar spine, such as spinal stenosis, degenerative disc disease, and spondylolisthesis
Patients were selected for the Dynesys Transition Optima (DTO) procedure if they presented with moderate degenerative stenosis adjacent to sections of significant spinal instability in which a rigid fusion was deemed indicated
Summary
The development of adjacent-segment disease is a recognized consequence of lumbar fusion surgery. This study presents the experience of using a hybrid dynamic stabilization and fusion construct for degenerative lumbar spine pathology in place of rigid arthrodesis. Studies have shown a high degree of variability in the efficacy of spinal fusion, with revision rates as high as 36% in some instances [1, 3]. Lumbar fusion carries a significant risk for the development of adjacent segment disease (ASD) with incidence rates reportedly as high as 30%, resulting in increased morbidity and subsequent revision surgery [4]. ASD is thought to be caused by abnormal biomechanical forces imparted by the rigid spine, which advances symptomatic degenerative changes in the immediately adjacent mobile segments [5]
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