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Lumbar adjacent segment disease


Introduction

Back pain is prevalent in the United States and worldwide. Lumbar arthrodesis techniques are being increasingly used to address congenital, degenerative, and traumatic spinal pathologies. Adjacent segment degeneration continues to be a very common sequela of lumbar arthrodesis occurring in up to 77% of patients and resulting in back pain and progressive neurological deficits. The treatment is surgical and should be tailored to the patient. A thorough understanding of the spine anatomy and biomechanics, as well as expertise with the various surgical techniques, is of utmost importance. In this chapter, we utilize a case example to illustrate the clinical presentation and surgical management of lumbar adjacent segment disease.

Example case

  • Chief complaint : back pain

  • History of present illness : The patient is a 71-year-old male with history of lumbosacral spondylosis and previous L4-S1 decompression and fusion at an outside institution. He now presents with a 6-month history of back pain and bilateral leg pain when walking. Lumbar spine imaging showed transitional vertebral anatomy with six lumbar vertebrae and adjacent segment degeneration at the L3–4 level with L3–4 disc herniation and ligamentum flavum and facet hypertrophy causing severe canal and neuroforaminal stenosis ( Figs. 5.1 and 5.2 ).

    Fig. 5.1, Preoperative x-rays and computed tomography scans

    Fig. 5.2, Preoperative magnetic resonance imaging

  • Medications : oxycodone, aspirin 81 mg

  • Allergies : no known allergies

  • Past medical history : coronary artery disease, benign prostate hyperplasia

  • Past surgical history : previous L3-S1 fusion and decompression 2 years prior

  • Family history : no history of malignancies

  • Social history : no smoking, occasional alcohol

  • Physical examination : awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes : 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle and no clonus or Babinski; sensation intact to light touch; negative straight leg raise and hip motion testing

  • Laboratories : all within normal limits

  • Ali A Baaj, MD

  • Neurosurgery

  • Weill Cornell

  • New York, New York, United States

  • Ahmed S. Barakat, MD

  • Orthopaedic Surgery

  • University of Cairo

  • Cairo, Egypt

  • Nitin N. Bhatia, MD

  • Orthopaedic Surgery

  • University of California at Irvine

  • Orange, California, United States

  • Claudio Yampolsky, MD

  • Neurosurgery

  • Hospital Italiano de Buenos Aires

  • Buenos Aires, Argentina

Preoperative
Additional tests requested

  • CT L-spine to assess fusion

  • Standing scoliosis x-rays for sagittal and coronal balance

  • DEXA bone scan

  • Physical therapy and/or ESI

  • MRI L-spine

  • CT L-spine

  • Echocardiogram

  • Cardiac evaluation

  • Flexion-extension L-spine x-rays

  • Standing full length 36-inch x-rays

  • CT L-spine

  • DEXA bone scan

  • Infection labs (ESR/CRP/EBC)

  • Flexion-extension L-spine x-rays

  • CT L-spine

Surgical approach selected L2–3 laminectomy and extension of prior fusion L2-S1 L2–3 TLIF and extension of prior fusion L2-S1 L2–3 laminectomy with bilateral facetectomy, L2–3 TLIF, exploration of L3-S1 fusion with revision fusion if needed If clear evidence of compression, L2–3 XLIF or DLIF and L2-S1 fusion
Goal of surgery Decompression of the adjacent segment, stabilization Decompression, stabilization Decompression, fusion Decompression, stabilization
Perioperative
Positioning Prone Prone Prone with four-post spine frame Lateral, then prone
Surgical equipment

  • IOM

  • Surgical microscope

Cell saver

  • IOM

  • Fluoroscopy

  • IOM

  • Fluoroscopy

  • Surgical navigation

Medications Antibiotics Tranexamic acid Perioperative pain regimen None
Anatomical considerations Traversing and exiting nerve roots, central canal Nerve root, dura Previously decompressed spinal canal Psoas muscle, lumbar plexus, vasculature, kidneys
Complications feared with approach chosen Pseudoarthrosis, CSF leak, residual stenosis Pseudoarthrosis, pedicle fracture, endplate fracture, neurological injury CSF leak, neurological injury Vascular injury, lumbar plexus injury, infection
Intraoperative
Anesthesia General, ERAS General General General
Exposure L2-S1 L2-S1 L2-S1 L2–3
Levels decompressed L2–3 L2–3 L2–3 L2–3
Levels fused L2-S1 L2-S1 L2-S1 L2-S1
Surgical narrative Incision opened and extended, previous hardware identified and removed, new hardware placed from L2-S1 with consideration for possible L2–3 only if fusion is good, L2–3 laminectomy, interbody or posterolateral fusion, plastic surgery closure Prone position, midline incision from L2-S1, evaluate previous hardware, replace loose screws with larger diameter screws, place L2 pedicle screws, L2–3 TLIF, connect screws with larger stiff rod, vancomycin powder in the incision, closure with subfascial drain Prone position, midline posterior incision utilizing previous incision, residual L2–3 spinous process will be identified along with scar from previous decompression, dissection carried laterally to identify L2–3 facet joint/L2 traverse process/previous instrumentation, remove previous caps and rods removed, hardware and fusion examined, replace hardware if loose with larger diameter and length hardware based on preoperative CT, leave hardware if fusion is solid, place pedicle screws at L2, decompress L2–3 with bilateral hemilaminectomies with subtotal vs. total facetectomies, interbody fusion with cage application with attention toward maintaining sagittal and coronal alignment, place new rods and caps, posterolateral fusion by connecting L2 transverse process to previous fusion mass using auto and allograft, vancomycin powder in surgical cavity, wound closed in layers with subfascial drain Lateral decubitus position, lateral incision after confirming with x-ray, minimal dissection, retractor placement over psoas muscle, monitoring of psoas muscle, annulotomy over confirmed disc space, discectomy, placement of cage with bone graft placement, reposition prone, extend fusion to L2, layered closure
Complication avoidance Limited to level of stenosis, plastic surgery closure Replace loose screws with larger diameter screws Evaluate previous hardware intraoperatively, bilateral hemilaminectomies Lateral approach, psoas monitoring, posterior supplementation
Postoperative
Admission Floor Intermediate care Floor Floor
Postoperative complications feared Hematoma, new radiculopathy Neurological injury, wound healing Hematoma, CSF leak, hardware malposition, neuropraxia Vascular injury, lumbar plexus injury, infection
Anticipated length of stay 2–3 days 4 days 2–4 days 2–3 days
Follow-up testing Upright AP/lateral L-spine x-rays after surgery AP/lateral lumbar x-rays 2 days after surgery Standing x-rays within 48 hours, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery

  • L-spine AP/lateral x-rays within 48 hours, 30 days after surgery

  • MRI L-spine 3 months after surgery

  • CT L-spine 3 months after surgery

Bracing None None None None
Follow-up visits 2 weeks for wound check; 3, 12, and 24 months 2 weeks, 3 months, 6 months, 12 months after surgery 2–3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery 7 days, 3 months after surgery
AP , Anteroposterior; CRP , C-reactive protein; CSF , cerebrospinal fluid; CT , computed tomography; ERAS , enhanced recovery after surgery; ESI , epidural spinal injections; ESR , erythrocyte sedimentation rate; IOM , intraoperative monitoring; MRI , magnetic resonance imaging; WBC , white blood cell count.

Differential diagnosis

  • ▪

    Lumbar facet syndrome

  • ▪

    Lumbar stenosis

  • ▪

    Lumbar adjacent segment disease

  • ▪

    Metastasis

  • ▪

    Primary extradural spine tumor

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