Adjacent Segment Degeneration Disease Research Articles

Complex neuroimaging study of the proximal segment after rigid fixation and dynamic stabilization in patients with degenerative lumbar disease

Background. The development of the adjacent level syndrome and, as a consequence, adjacent segment degenerative disease are currently the most common complications of decompression and stabilization surgery with the development of segmental instability. The aim of the study. To conduct a comprehensive neuroimaging assessment of the proximal adjacent segment after rigid fixation and dynamic stabilization in degenerative lumbar disease. Materials and methods. We conducted a prospective multicenter study of the results of surgical treatment of 274 patients with degenerative-dystrophic diseases of the lumbar spine, who underwent monosegmental decompression and stabilization surgery using the TLIF (transforaminal lumbar interbody fusion) technique and open transpedicular rigid fixation, as well as open hemilaminectomy with stabilization of the operated segments with nitinol rods. The study included radiography, diffusion-weighted magnetic resonance imaging and computed tomography (dualenergy mode) of intervertebral discs and isolated facet degeneration of the upper adjacent level. Results and discussion. Combination of the initial proximal segment degeneration in the form of facet joints degeneration (density of cartilaginous plate – 163.5 ± 14.2 HU, density of external facet – 709.35 ± 13.6 HU, density of internal facet – 578.1 ± 12.1 HU), Pfirrmann III, IV grade degeneration of intervertebral disc and a measured diffusion coefficient of less than 1300 mm2/s cause high risks of developing adjacent segment degenerative disease, which regulates the use of monosegmental dynamic fixation with nitinol rods, or preventive rigid fixation of the adjacent segment. Conclusion. Using complex neuroimaging in the preoperative period makes it possible to predict the results of surgical treatment, take timely measures to prevent degenerative diseases of the adjacent segment, and to carry out dynamic monitoring of processes in the structures of the spinal motion segment.

Analysis of preoperative risk factors of adjacent segment disease after transforaminal lumbar interbody fusion

To evaluate the effect of preoperative biometric and instrumental parameters of adjacent FSU on the risk of ASDd after transforaminal lumbar interbody fusion and determine personalized neurosurgical approach. We retrospectively studied patients after single-level transforaminal lumbar interbody fusion (group I, n=54), single-level transforaminal lumbar interbody fusion and interspinous stabilization of adjacent level (group II, n=55), preventive rigid fusion of adjacent segment (group III, n=56). Preoperative parameters and long-term clinical outcomes were assessed. Paired correlation analysis established the main predictors of ASDd. Regression analysis determined absolute values of these predictors for each type of surgical intervention. Surgical intervention at the level of asymptomatic proximal adjacent segment is recommended as interspinous stabilization for moderate degenerative lesions, BMI <25 kg/m2, difference between pelvic index and lumbar lordosis 10.5-15°, segmental lordosis 6.5-10.5°. In case of severe degenerative lesions, BMI 25.1-31.1 kg/m2, significant deviations of spinal-pelvic parameters (segmental lordosis 5.5-10.5°, difference between pelvic index and lumbar lordosis 15.2-20°), preventive rigid stabilization is indicated.

Longitudinal Spinous-Splitting Laminoplasty with Coral Bone for the Treatment of Cervical Adjacent Segment Degenerative Disease: A 5-Year Follow-up Study.

This study was designed to analyze the causes of cervical adjacent segment degenerative disease (ASDis), evaluate the surgical outcomes of longitudinal spinous‐splitting laminoplasty with coral bone (SLAC) during cervical reoperation, and accumulate data on reoperation with SLAC in a primary hospital. Based on the inclusion and exclusion criteria, we conducted a retrospective study involving 52 patients who underwent cervical reoperation for ASDis using SLAC at the spinal surgery department of the Beijing Jishuitan Hospital from 1998 to 2014. Among them, 39 were treated with anterior cervical fusion and internal fixation during the first operation (anterior cervical corpectomy with fusion [ACCF], n = 24; anterior cervical discectomy and fusion [ACDF], n = 11; and cervical disc arthroplasty [CDA], n = 4). Outcomes were the Japanese Orthopaedic Association (JOA) score, neck disability index (NDI) score, upper limb/neck and shoulder evaluated using a visual analogue scale (VAS), and rates of ASDis. In patients who underwent an anterior cervical approach in the first instance, the incidence of ASDis was significantly higher in the C3/4 gap than in the other gaps. In the ACCF group, the lateral radiograph of the cervical spine revealed that the distance between the anterior cervical plate and the adjacent segment disc was <5 mm in 15 (62.5%) cases and five (12.8%) cases, respectively, the internal fixation screws broke into the annulus of the adjacent segment. After the first SLAC, ASDis developed at C2/3 and C3/4 in four (30.8%) and eight (61.5%) cases, respectively. After reoperation, all cases were followed up for >5 (average, 6.2) years. The pre‐reoperation and last follow‐up values were as follows: mean Japanese Orthopaedic Association score, 10.2 ± 1.5 vs 15.5 ± 0.7 (P = 0.03); neck disability index, 26.2 vs 13.6 points (P = 0.01); upper‐limb visual analog scale (VAS) score, 6.1 vs 2.6 points (P = 0.04); and neck and shoulder VAS score, 6.6 vs 2.1 points (P = 0.03). SLAC is a simple technique in which the local anatomy is clearly visible and satisfactory clinical outcomes are obtained.

Analysis of the influence parameters spine-pelvic balance on the risk of development degeneration and degenerative disease of adjacent segments after lumbar spine rigid fixation

Introduction An increase in the load on adjacent segments causes changes in the parameters of the spinal-pelvic balance and, as a consequence, the development of the so-called biomechanical «stress». Such pressures are a key link in the pathogenesis of degeneration, and in the presence of clinical and neurological manifestations of the latter and adjacent segment degenerative disease (ASD/ASDd).Objective of this study was to assess the effect of the parameters of the spinal pelvic balance on the risk of developing ASD/ASDd after dorsal decompression-stabilizing interventions (DDSI).Material and Methods The study included medical records of patients who underwent DDSI for lumbar spine degenerative diseases. Clinical and instrumental parameters were assessed.Results Based on the inclusion criteria, 98 patients (48 with signs of ASD/ASDd and 50 without) were included in the study. The average postoperative follow-up period for the respondents was 46.6 ± 9.8 months. If PI/ LL parameters were &lt;10 and the ratio of segmental and global lumbar lordosis (LIV-SI/LI-SI) was 50% or more, the incidence of ASD/ASDd was significantly lower in patients who underwent rigid lumbar stabilization surgery.Conclusion The values of PI/LL parameters and the ratio of segmental and global lumbar lordosis are obvious risk factors for the development of ASD/ASDd after rigid lumbar spine DDSI.

Cervical Spine Endplate Abnormalities and Association With Pain, Disability, and Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion.

A retrospective study with prospectively-collected data. To determine how type, location, and size of endplate lesions on magnetic resonance imaging (MRI) may be associated with symptoms and clinical outcomes after anterior cervical discectomy and fusion (ACDF). Structural endplate abnormalities are important, yet understudied, phenomena in the cervical spine. ACDF is a common surgical treatment for degenerative disc disease; however, adjacent segment degeneration/disease (ASD) may develop. Assessed the imaging, symptoms and clinical outcomes of 861 patients who underwent ACDF at a single center. MRI and plain radiographs of the cervical spine were evaluated. Endplate abnormalities on MRI were identified and stratified by type (atypical, typical), location, relation to operative levels, presence at the adjacent level, and size. These strata were assessed for association with presenting symptoms, patient-reported, and postoperative outcomes. Of 861 patients (mean follow-up: 17.4 months), 57.3% had evidence of endplate abnormalities, 39.0% had typical abnormalities, while 18.2% had atypical abnormalities. Patients with any endplate abnormality had greater odds of myelopathy irrespective of location or size, while sensory deficits were associated with atypical lesions (P = 0.016). Typical and atypical abnormalities demonstrated differences in patient-reported outcomes based on location relative to the fused segment. Typical variants were not associated with adverse surgical outcomes, while atypical lesions were associated with ASD (irrespective of size/location; P = 0.004) and reoperations, when a large abnormality was present at the proximal adjacent level (P = 0.025). This is the first study to examine endplate abnormalities on MRI of the cervical spine, demonstrating distinct risk profiles for symptoms, patient-reported, and surgical outcomes after ACDF. Patients with typical lesions reported worsening postoperative pain/disability, while those with atypical abnormalities experienced greater rates of ASD and reoperation. This highlights the relevance of a degenerative spine phenotypic assessment, and suggests endplate abnormalities may prognosticate clinical outcomes after surgery. 3.

Decompression with fusion is not in superiority to decompression alone in lumbar stenosis based on randomized controlled trials: A PRISMA-compliant meta-analysis.

Although some studies had been published, it was more controversial on the superiority of decompression alone (D) and decompression with fusion (F) for the treatment of lumbar spinal stenosis (LSS) recently, especially newest articles with different opinions. A meta-analysis was performed to compare efficacy on D and F for LSS regardless of degenerative spondylolisthesis (DS) with randomized controlled trials (RCTs). The databases include PUBMED/MEDLINE, EMBASE, Cochrane Library, and Web of Science from January 1970 to December 2018. The information of screened studies included demographics, clinical outcomes, and secondary measures, then data synthesis and meta-analysis were progressed. Subgroup analysis was stratified by DS and follow-up time (36 months). Continuous variables and dichotomous variables were respectively reported as weighted mean difference and odds ratios (ORs). The strength of evidence was evaluated by the grades of recommendation, assessment, development, and evaluation (GRADE) system. Nine RCTs met inclusion criteria with a total of 857 patients (367 were in D group and 490 were in F group). There were no statistical difference in visual analog scale changes on back and leg pain between D and F group (mean difference [MD] = -0.03, 95% confidence interval [CI] [-0.38, 0.76], z = 0.08, P = .94; MD = 0.11, 95% CI [-1.08, 1.30], z = 0.18, P = .86, respectively); patients' satisfaction was of no difference between the 2 groups, together with the change of the Oswestry disability index and European quality of life-5 dimensions (P > .05). There were no difference in the rate of complication (P = .50) and reoperation (P = .11) while a statistical significance of longer operation duration (P < .0001), more blood loss (P = .004) but amazing lower rate of adjacent segment degenerative/disease (ASD) (OR = 2.35, P = .02) in F group. The subgroup analysis on DS showed that basically all measures were in consistency with meta-analysis. There was a higher reoperation rate in middle-to-long term (>36 months) in D group and ASD was the most seasons of reoperation no matter the follow-up time. According to the GRADE system, the grade of this meta-analysis was of "High" quality. F group has no better clinical results than D alone in LSS, regardless of DS and follow-up. The conclusion is of "High" quality and the grade strength of recommendation was "Strong."

Decompression with fusion is not superior to decompression alone in lumbar short-segment stenosis based on randomized controlled trials: meta-analysis

Objective A meta-analysis is to be performed to compare the entire efficacy on decompression (D) alone and decompression with fusion (F) for patients with 1-2 level lumbar stenosis (LSS) regardless of degenerative spondylolisthesis (DS) based on published RCTs. Methods The databases include Pubmed, Embase, Cochrane Library and Web of Science from January 1970 to March 2018 with a certain search strategy and inclusion criteria. Two reviewers assessed eligible trials, evaluated articles quality and extracted information independently and the information included basic characteristics of demographic information, primary and secondary measures, then data synthesis and meta-analysis was progressed as well as subgroup analysis by DS and follow-up time (36 months). Continuous variables were reported as weighted mean difference (WMD) and dichotomous variables were reported as odds ratios (ORs). Finally the strength of evidence and grade of recommendation was evaluated by the grades of recommendation, assessment, development and evaluation (GRADE) system for the overall outcome. Results A total of 9 RCTs with a low to moderate risk of bias met inclusion criteria with a total of 857 patients (367 were in D group and 490 were in F group) in 1-2 level operation and the average age, sex ratio and preoperative visual analogue scale (VAS) were of no significance. In primary measures, there were no statistical difference in VAS changes on back and leg pain between D and F group[MD=-0.03, 95% CI (-0.38, 0.76), Z=0.08, P=0.94; MD=0.11, 95%CI (-1.08, 1.30), Z=0.18, P=0.86, respectively]; Patients' satisfaction was of no difference between the two groups (OR=0.74, P=0.48), together with the change of Oswestry disability index (ODI, P=0.29) and European quality of life-5 dimensions (EQ-5D, P=0.41). As to the secondary measures, there were no difference in the rate of complication (OR=0.75, P=0.50) and reoperation (OR=1.93, P=0.11) while a statistical significance of longer operation duration (P=0.000), more blood loss (P=0.004), longer hospital stays (P=0.000) but amazing lower rate of ASD (OR=2.35, P=0.02) in F group. The subgroup analysis on whether combined with DS showed that basically all of the compared measures were in consistency with the whole meta-analysis; As to the follow-up, there was a higher reoperation rate in middle-to-long term (>36months) in D group while the other measures were in line with the overall meta-analysis and adjacent segment degeneration/disease (ASD) was the most seasons of reoperation yet no matter the follow-up time. According to the GRADE system, the grade of this meta-analysis is of High quality. Conclusion F group has no better clinical results than D alone in short-segment LSS, regardless of DS, and even further, no significant change with shot-term or middle-to-long term follow-up. F approach has a longer duration of operation, more hospital stays and more blood loss, even perhaps a lager cost. According to the GRADE, the grade of this meta-analysis is of High quality, the grade strength of recommendation was Strong . Key words: Spinal stenosis; Spondylolysis; Decompression, surgical; Spinal fusion

Posterior Lumbar Interbody Fusion in Degenerative Spondylolisthesis

Background: degenerative spondylolisthesis is one of causes of low back pain in older patients and it’s referring to a forward slippage of a lumbar, with an intact neural arch. Uncommon before the age of 50 years, it is more common in women and particularly in blacks, with a male: female ratio of 1:6. Posterior lumbar interbody fusion surgery is one of an effective surgery in treatment of patients with degenerative spondylolisthesis and can make significant relief in low back pain and disability. It has amore advantages more than other type of back surgery through restoring of vertebral height and restricts motion of the vertebral segment. Objective: this study aimed to evaluate the surgical treatment of degenerative spondylolisthesis by Posterior Lumber Interbody Fusion. Patients and Methods: this was a prospective study carried out at Al-Azhar University Hospitals on 15 patients with degenerative spondylolithesis operated by posterior lumber interbody fusion and assessment pre-operative, one day, three months and six months post-operative by oswestry disability index .also according to visual analogue scale pre and post-operative then assessment of the fusion according to lenke classification. Results: the mean preoperative ODI was (70.2%±5.5) one day Postoperative ODI was (10.93%±4.76), after 3 months was (10.67±7.97) and 6 months the mean post-operative was (12.76±14.25). According to VAS for back pain pre-operative was (6.9± 0.9) preoperative and show marked improvement and the main postoperative value according to VAS is (1.53±1.126) for leg pain The mean value Pre-operative according to VAS was :(9.06±0.7) and the mean value Post operativeis (2.0±1.41) the mean outcome was 87.24 % ranged from 38% to 94% the main complication noted the adjacent segment degenerative disease and Dural tear. Conclusion: posterior lumber interbody fusion in degenerative spondylolisthesis is a very good option.

Cervical Disk Replacement With Discover Versus Fusion in a Single-Level Cervical Disk Disease: A Prospective Single-Center Randomized Trial With a Minimum 2-Year Follow-up.

Prospective randomized study. To compare the clinical outcome after Discover arthroplasty versus anterior cervical discectomy and fusion (ACDF) in patients treated for symptomatic single-level cervical disk disease. ACDF is still the gold standard for surgical treatment of cervical spine degenerative disk disease. However, results of many studies suggest that it may cause degenerative changes at levels immediately above and below the fusion, known as adjacent segment degenerative disease. Cervical arthroplasty has recently been introduced as an alternative to standard procedure of ACDF. It showed decreased surgical morbidity, decreased complications from postoperative immobilization, and an earlier return to previous level of function. A total of 105 consecutive patients with single-level cervical disk disease, producing radiculopathy and/or myelopathy were randomly divided into groups to undergo ACDF or Discover arthroplasty. All patients were evaluated with preoperative and postoperative serial radiographic studies and clinically, using Neck Disability Index, Visual Analog Scale and neurological status at 3, 6, 12, and 24 months. The results of our study indicate that cervical arthroplasty using Discover Artificial Cervical Disc provides favorable clinical and radiologic outcomes in a follow-up period of 24 months. There has been significant improvement in clinical parameters, Visual Analog Scale and Neck Disability Index, at 3, 6, 12, and 24 months in arthroplasty group comparing to control group. The Discover artificial cervical disc replacement offers favorable outcome compared with ACDF for a single-level cervical disk disease at short-term and long-term follow-up.

There is no increased risk of adjacent segment disease at the cervicothoracic junction following an anterior cervical discectomy and fusion to C7

Background ContextAnterior cervical discectomy and fusion (ACDF) is a very common operative intervention for the treatment of cervical spine degenerative disease in those who have failed non-operative measures. However, studies examining long-term follow-up on patients who underwent ACDF reveal evidence of radiographic and clinical degenerative disc disease at the levels adjacent to the fusion construct. Consistent with other junctional regions of the spine, the cervicothoracic junction (CTJ) has significant morphologic variations. As a result, the CTJ undergoes significant static and dynamic stress. Given these findings, there has been some thought that ACDF down to C7 may experience additional risks for adjacent segment degeneration/disease (ASD) when compared with ASDFs that are cephalad to C7. PurposeThe goal of this study is to evaluate the rate of radiographic and clinical ASD in patients who have undergone single- or multilevel ACDF, down to C7. Study DesignThis is a retrospective cohort study. Patient SampleThe sample included consecutive patients from a single orthopedic surgeon at one quaternary referral medical center who underwent an ACDF between January 2008 and November 2014. Indications for surgery included radiculopathy, myelopathy, or myeloradiculopathy in the setting of failed conservative treatments. Patients were excluded if they had an ACDF of which the caudal level was cephalad to C7 or if they had undergone a previous cervical fusion. Outcome MeasuresRadiographic diagnosis of ASD was determined by the presence of disc space narrowing >50%, new or enlarged osteophytes, end plate sclerosis, or increased calcification of the anterior longitudinal ligament (ALL). Postoperatively, data were collected on the presence of new radicular or myelopathic symptoms indicative of pathology at C7–T1, indicating a diagnosis of clinical ASD. MethodsDemographic information was collected for all patients, which included age, sex, body mass index, smoking status, and Charleston Comorbidity Index (CCI). Several radiographic parameters were measured preoperatively, immediately postoperatively, and at the last follow-up: C2–C7 lordosis, sagittal vertical axis (SVA), thoracic inlet angle (TIA), and T1 slope C2–C7 lordosis were measured using the Cobb angle between the inferior end plate of C2 to the inferior end plate of C7. Radiographic and clinical factors associated with ASD were analyzed postoperatively. ResultsFour patients (4.8%) presented with clinical evidence of ASD, all of whom also showed signs of radiographic ASD and improved with conservative measures. No patients underwent reoperation for ASD at the C7–T1 junction. Thirty patients (36.1%) presented radiographic evidence of ASD. These were generally older (54.4 vs. 48.4 years; p=.014). There were neither significant differences in radiographic parameters nor between single- versus multilevel ACDFs and the development of ASD. ConclusionsThe cervicothoracic junction may present with vulnerability to ASD given the junctional biomechanics. However, this study provides evidence that an ACDF with the caudal level of C7 does not incur additional risk of ASD, showing similar outcomes to ACDFs at other levels.

Adjacent Segment Degenerative Disease: Is It Due to Disease Progression or a Fusion-Associated Phenomenon?

Adjacent Segment Degenerative Disease: Is It Due to Disease Progression or a Fusion-Associated Phenomenon?

Adjacent segment degenerative disease: is it due to disease progression or a fusion-associated phenomenon? Comparison between segments adjacent to the fused and non-fused segments. Song KJ, Choi BW, Jeon TS, Lee KB, Chang H. Eur Spine J 2011 Jun 8. [Epub ahead of print

Adjacent segment degenerative disease: is it due to disease progression or a fusion-associated phenomenon? Comparison between segments adjacent to the fused and non-fused segments. Song KJ, Choi BW, Jeon TS, Lee KB, Chang H. Eur Spine J 2011 Jun 8. [Epub ahead of print

Adjacent segment degenerative disease: is it due to disease progression or a fusion-associated phenomenon? Comparison between segments adjacent to the fused and non-fused segments

The purpose of this study was to determine whether fusion causes adjacent segment degeneration or whether degeneration is due to disease progression. Eighty-seven patients that had undergone single level anterior cervical decompression and fusions with at least 5years of follow-up were enrolled in this retrospective study. Segments adjacent to fusion levels (above or below) were allocated to group A, and all others were allocated to group B. Radiographic evaluations of adjacent level changes included assessments of; disc degenerative changes, anterior ossification formation, and segmental instability. The developments of new clinical symptoms were also evaluated. In group A, adjacent segment degenerative change developed in 28 segments (16%) and two cases (2%) developed new clinical symptoms. In group B, adjacent segment degenerative change developed in 10 segments (3%), and two cases (0.7%) also developed new clinical symptoms. Additional operations were performed in one patient in each group. Although, fusion per se can accelerate the severity of adjacent level degeneration, no significant difference was observed between adjacent and non-adjacent segments in terms of the incidence of symptomatic disease. The authors conclude that adjacent segment disease is more a result of the natural history of cervical spondylosis than the presence of fusion.

New progress in adjacent segment degeneration/disease

Adjacent segment degeneration/disease (ASD) has been generally accepted as a long-term complication after spinal surgery. Although the incidence of ASD is not very high, it is gradually recognized to be a very important factor in evaluation of the long-term effect of spinal fusion. There are many views concerning pathogenic factors and ways of prevention and treatment. The authors review and discuss the current research and this article will describe recent advances in ASD.