title: Adjacent segment disease followinglumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up.
abstract: METHODS
  Retrospective radiographic outcomes analysis.
  
  
  OBJECTIVE
  We had 3 hypotheses: 1) a longer fusion; 2) a more proximal instrumented vertebra, and 3) circumferential fusion versus posterior-only fusion would increase the likelihood of adjacent segment disease (ASD).
  
  
  BACKGROUND
  The literature analyzing risk factors, prevalence, and presentation of patients with ASD is varied and without clear consensus.
  
  
  METHODS
  A total of 188 patients with minimum 5-year follow-up who had lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative disorders were included. Radiographic ASD was defined by: 1) development of spondylolisthesis >4 mm, 2) segmental kyphosis >10 degrees , 3) complete collapse of disc space, or 4) more than 2 grades worsening of Weiner classification. Clinical ASD was defined as 1) symptomatic spinal stenosis, 2) intractable back pain, or 3) subsequent sagittal or coronal imbalance.
  
  
  RESULTS
  Radiographic ASD occurred in 42.6% (80 of 188) of patients. Patients with radiographic ASD had worse Oswestry scores (20.3 vs. 12.5; P = 0.001) at ultimate follow-up than those without ASD. Clinical ASD developed in 30.3% (57 of 188) of patients. Clinical ASD manifested as spinal stenosis (n = 47), instability-type back pain (n = 5), and sagittal or coronal imbalance (n = 5). Age at surgery over 50 years and length of fusion were significant risk factors for the development of ASD in the lumbar spine. Fusion to L1-L3 proximally increased the risk of ASD when compared with L4 and L5. Circumferential fusion versus posterior fusion was not a significant factor in the development of ASD.
  
  
  CONCLUSIONS
  Patients over the age of 50 were at higher risk of developing clinical ASD than those 50 years old or younger. Length of fusion was a significant risk factor in the development of ASD in the lumbar spine. Fusion up to L1-L3 increased the risk of ASD when compared with L4 and L5. Circumferential fusion, as opposed to posterolateral fusion, was not a statistically significant risk factor for the development of ASD.
authors.affiliation: Department of Orthopaedic Surgery, Wooridul Spine Hospital, Seoul, Korea.
authors.forename: Gene
authors.initials: G
authors.lastname: Cheh
authors.forename: Keith H
authors.initials: KH
authors.lastname: Bridwell
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Jacob M
authors.initials: JM
authors.lastname: Buchowski
authors.forename: Michael D
authors.initials: MD
authors.lastname: Daubs
authors.forename: Yongjung
authors.initials: Y
authors.lastname: Kim
authors.forename: Christy
authors.initials: C
authors.lastname: Baldus
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001416:Back Pain / Q000209:etiology; D001863:Bone Screws; D004185:Disability Evaluation; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007738:Kyphosis / Q000209:etiology; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010148:Intractable Pain / Q000209:etiology; D004856:Postural Balance; D015995:Prevalence; D011859:Radiography; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000503:physiopathology; D013123:Spinal Fusion / Q000295:instrumentation* / Q000379:methods; D013130:Spinal Stenosis / Q000209:etiology; D013168:Spondylolisthesis / Q000209:etiology; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome