title: Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5-S1 disc, minimum 5-year follow-up.
abstract: METHODS
  A retrospective long-term follow-up study.
  
  
  OBJECTIVE
  Evaluate the fate of L5-S1 disc analyzing subsequent disc degeneration and associated risk factors for degeneration at minimum 5-year follow-up (average 9-year follow-up).
  
  
  BACKGROUND
  Two previous studies reported the results of long deformity fusions terminating at L5 with minimum 2-year follow-up only.
  
  
  METHODS
  Thirty-one consecutive patients with an average age of 45 years (range, 20-62 years) were fused from the thoracic spine to L5 and were evaluated at a mean follow-up of 9.4 years (range, 5-20.1 year). Patients were evaluated before surgery, after surgery, and latest follow-up with radiographs and Scoliosis Research Society Patient Questionnaire-24 scores. Disc degeneration using validated radiographic Weiner grades. Grade 0 to 1 discs were "healthy" and Grade 2 to 3 were degenerated. Patients with "healthy" discs preoperative that subsequently degenerated were designated subsequent advanced degeneration (SAD).
  
  
  RESULTS
  Two out of 31 patients had preoperative advanced degeneration of the L5-S1 disc (Weiner grade 2-3). Three additional patients had an early revision to the sacrum secondary to sagittal imbalance not thought to be related to SAD. Twenty-six out of 31 patients were assessed as "healthy discs" preoperative (Weiner grade 0-1) and were evaluated for SAD. By latest follow-up, L5-S1 SAD developed in 18 of these 26 patients (69%). Risk factors for the development of SAD included long fusions extending into the upper thoracic spine down to L5 (P = 0.02) and having a circumferential lumbar fusion (P = 0.02). Although preoperative sagittal balance was not significantly different between the "healthy" and SAD group, sagittal balance at follow-up was: C7 plumb >5 cm in 67% of SAD patients and only 13% of "healthy" disc patients (P = 0.009). There was a trend toward inferior Scoliosis Research Society Patient Questionnaire-24 pain scores at follow-up in SAD patients (average score 4.1 vs. 3.4, P = 0.13). Eleven out of 30 patients (35%) had subsequent spinal surgery with 7 of 31 (23%) having extension of their fusion to the sacrum. An additional 6 of 31 (19%) were considered for extension to the sacrum but comorbidities precluded surgery (3 patients) or the patients declined further surgery (3 patients).
  
  
  CONCLUSIONS
  Advanced L5-S1 DDD developed in 69% of deformity patients after long fusions to L5 with 5 to 15 year follow-up. SAD frequently results in significant positive sagittal balance at a minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5 and circumferential fusion may further promote subsequent L5-S1 disc degeneration.
authors.affiliation: Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA.
authors.forename: Craig A
authors.initials: CA
authors.lastname: Kuhns
authors.forename: Keith H
authors.initials: KH
authors.lastname: Bridwell
authors.forename: Lawrence G
authors.initials: LG
authors.lastname: Lenke
authors.forename: Courtney
authors.initials: C
authors.lastname: Amor
authors.forename: Ronald A
authors.initials: RA
authors.lastname: Lehman
authors.forename: Jacob M
authors.initials: JM
authors.lastname: Buchowski
authors.forename: Charles
authors.initials: C
authors.lastname: Edwards
authors.forename: Baldus
authors.initials: B
authors.lastname: Christine
mesh_terms: D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000000981:diagnostic imaging / Q000453:epidemiology*; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000453:epidemiology*; D011859:Radiography; D012189:Retrospective Studies; D012307:Risk Factors; D012447:Sacrum / Q000000981:diagnostic imaging / Q000601:surgery*; D013122:Spinal Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods* / Q000706:statistics & numerical data; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D016896:Treatment Outcome