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- v.40; 2023 Jun
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J Orthop. 2023 Jun; 40: 52–56.
Published online 2023 Apr 25. doi:10.1016/j.jor.2023.04.009
PMCID: PMC10172830
PMID: 37188147
Taylor Paziuk,a,∗ Brian J. Neuman,b William Conaway,a Parth Kothari,a Tyler W. Henry,a Christopher K. Kepler,a Gregory D. Schroeder,a Alexander R. Vaccaro,a and Alan S. Hilibranda
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Abstract
Background
The treatment for multi-level spinal stenosis in the setting of single-level instability is a common operative scenario for surgeons who treat degenerative lumbar spine pathology. However, there is conflicting evidence regarding the inclusion of adjacent “stable” levels in the arthrodesis construct because of the potential for iatrogenic instability placed on those segments with decompressive laminectomy alone. This study aims to determine whether decompression adjacent to arthrodesis in the lumbar spine is a risk factor for adjacent segment disease (AS Disease).
Methods
A retrospective analysis identified consecutive patients over a three-year period who underwent single-level posterolateral lumbar fusion (PLF) in the setting of single or multi-level spinal stenosis. Patients were required to have a minimum of two-year follow-up. AS Disease was defined as the development of new radicular symptoms referable to a motion segment adjacent to the lumbar arthrodesis construct. The incidence of AS Disease and reoperation rates were compared between cohorts.
Results
133 patients met the inclusion criteria with an average follow-up of 54 months. Fifty-four patients had a PLF with adjacent segment decompression, and 79 underwent a single-segment decompression and PLF. 24.1% (13/54) of patients who had a PLF with adjacent level decompression developed AS Disease resulting in a 5.5% (3/54) reoperation rate. 15.2% (12/79) of patients who did not receive an adjacent level decompression developed AS Disease resulting in a reoperation rate of 7.5% (6/79). There was neither a significantly higher rate of AS Disease (p=0.26) nor reoperation (p=0.74) between the cohorts.
Conclusions
Decompression adjacent to single-level PLF was not associated with an increased rate of AS Disease relative to single-level decompression and PLF.
Keywords: Adjacent segment disease, Spinal stenosis, Lumbar spine, Arthrodesis, Decompression
1. Introduction
Degenerative spinal stenosis and spondylolisthesis are common pathologies of the lumbar spine in an aging population. While many patients are successfully managed with conservative treatments, those who fail such modalities may require surgical intervention. Existing literature demonstrates the safety and efficacy of surgically managed lumbar spondylosis and associated stenosis.1, 2, 3 However, surgical strategies may vary, particularly when there is concomitant spinal stenosis adjacent to a spondylisthetic level. It has been postulated that performing a posterior decompression adjacent to the level of arthrodesis may impart instability on the adjacent segment by removing much of the posterior stabilizing column. To prevent this, some advocate for arthrodesis of decompressed adjacent levels because of the potential risk of developing adjacent segment degeneration (AS Degeneration) and, ultimately, adjacent segment disease (AS Disease). Critics of combined decompression and fusion highlight the potential downsides of extending a fusion construct, one of which is, ironically, an increased risk of developing both AS Degeneration and AS Disease. Consequently, it remains controversial whether or not patients with a single-level spondylolisthesis who require a multi-level laminectomy should be fused at all decompressed levels.4, 5, 6
The number of spinal arthrodesis surgeries performed annually in the United States exceeds 1.5 million and will continue to rise.7,8 Unfortunately, a recognized risk of such procedures is the development of spondylosis at levels adjacent to the original construct after arthrodesis. AS Degeneration is the accelerated degeneration of spinal segments adjacent to an arthrodesis construct. When this degenerative process results in clinical symptoms, it is deemed AS Disease.9 This condition may be due in part to the underlying predisposition to degeneration in patients with spondylotic pathology or related to altered biomechanics after spinal arthrodesis. However, multiple biomechanical and clinical investigatory efforts have yet to definitively identify the exact etiology of this accelerated degenerative process.8,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 Reported risk factors for the development of AS Disease include pre-existing adjacent level spondylosis, arthrodesis construct length, positive sagittal balance, increasing age, increasing body mass index (BMI), and the utilized arthrodesis technique.5,23
Some studies have analyzed the relationship between adjacent-level decompression and AS Disease with conflicting results. In 2004, Lai et al. reported that patients with a PLF and adjacent decompression had a nearly four times higher rate of developing AS Degeneration six years after surgery.24 Similarly, in 2014, Hikata et al. found that patients undergoing adjacent level decompression were nearly three times more likely to develop AS Disease.25 Conversely, Aiki et al. and Lee et al. found no associations between the development of AS Disease and PLF with adjacent decompression at an average follow-up of seven and six years after surgery, respectively.5,18 In part contributable to the conflicting findings existent within the literature, the decision to address adjacent levels with decompression alone versus decompression and fusion is highly surgeon-dependent.
The present study aimed to compare the rates of AS Disease among patients who underwent single-level posterolateral lumbar arthrodesis with or without adjacent segment decompression. We hypothesized that there would be no difference in the rates of AS Disease between patients undergoing single-level arthrodesis with adjacent decompression and those undergoing single-level decompression and arthrodesis alone.
2. Materials and methods
The records of all consecutive patients who underwent a single-level lumbar arthrodesis by any one of four senior spine surgeons at a single institution over three years were reviewed. All patients who underwent a primary single-level posterolateral lumbar arthrodesis for a symptomatic degenerative spondylolisthesis with associated spinal stenosis were included. Patients without a minimum of two-year follow-up were contacted by phone and administered a survey to determine the development of new symptoms and identify additional treatments. Patients that had any interbody stabilization procedure or an anterior arthrodesis during the index hospitalization were excluded. The charts of all patients meeting inclusion criteria were then reviewed to identify those who developed AS Disease, which was defined as the development of new radiculopathy or claudication referable to a motion segment adjacent to the lumbar arthrodesis with symptom duration greater than six weeks that persisted across two or more physician visits. The treatment methods for AS Disease were reviewed, and reoperation rates were calculated.
2.1. Operative indications
Patients who underwent lumbar decompression and arthrodesis had recalcitrant lower extremity radicular pain, weakness, or neurogenic claudication that failed nonoperative treatment modalities. Among all patients included in our analysis, there was evidence of a degenerative spondylolisthesis on neutral or dynamic flexion and extension radiographs. Additionally, all included patients had moderate to severe spinal stenosis at the involved levels, as seen on MRI or CT myelography. Preoperatively it was determined to stabilize the level of instability and decompress the spinal canal and nerve roots at all symptomatic levels where there was at least moderate stenosis.
2.2. Operative procedure
All patients underwent a single-level posterolateral lumbar arthrodesis. Those patients who underwent adjacent level decompression, in which part of the most cephalad and caudal laminae were removed and all of the lamina in between (e.g., the inferior portion of L3, all of L4 and the superior portion of L5 were removed for an L3-5 decompression), were subsequently classified as the “adjacent-level” cohort. Patients who underwent a single-level decompression, in which only portions of the lamina at the stabilized levels were decompressed (e.g., part/all of the L4 lamina and part/all of the L5 lamina) were subsequently classified as the “same-level” cohort.
2.3. Statistical methods
A Fisher's exact test was used to assess the rates of AS Disease between groups. A Spearman's correlation test was used to evaluate for potential correlations between the development of AS Disease with age, gender, and stabilized levels. Finally, Kaplan Meier survivorship analysis was performed to assess the disease-free survival rate for the entire population and each group.
3. Results
One hundred eighty-two patients underwent a single-level posterolateral lumbar arthrodesis without interbody stabilization (PLF) for degenerative spondylolisthesis. The “adjacent-level” cohort included 76 patients, and the “same-level” cohort included 106 patients. Of the 182 patients who underwent a single-level PLF, 133 had at least a 2-year follow-up in person or completed a telephone survey. None of the patients reached by telephone for final follow-up reported symptoms concerning for AS Disease requiring subsequent in-person evaluation. Of these 133 patients, 54 patients had a PLF with additional levels decompressed for multi-level stenosis above or below the arthrodesis (“adjacent-level” cohort), and 79 patients underwent a PLF with decompression only at the same segment (“same-level” cohort). The “adjacent-level” cohort included 31 females and 23 males with an average age of 67 years old. The average follow-up was 52 months (range 24–88 months). The majority of patients underwent L4-L5 PLF (Table 1, Table 2). There were 54 females and 25 males in the “same-level” cohort with an average age of 61 years old and an average follow-up of 55 months (range 24–108 months). The majority of patients also had an L4-L5 PLF (Table 1).
Table 1
The number and percentage of patients who underwent a posterolateral lumbar fusion at the corresponding level.
| PLF level | Total number of patients in Group I | Number of patients who developed ASD in Group I | Total number of patients in Group II | Number of patients who developed ASD in Group II |
|---|---|---|---|---|
| L2-L3 | 0 (0%) | 0 | 1 (1%) | 0 |
| L3-L4 | 7 (13%) | 0 | 9 (11%) | 2 (22%) |
| L4-L5 | 46 (85%) | 13 (28%) | 62 (79%) | 9 (14.5%) |
| L5-S1 | 1 (2%) | 0 | 7 (9%) | 1 (14.2%) |
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*PLF = Posterolateral Lumbar Fusion; ASD=Adjacent Segment Disease; Group I=patients who had a single-level PLF with additional levels decompressed; Group II=patients underwent a single-level laminectomy and PLF.
Table 2
The total number of patients based on Level of arthrodesis and their corresponding rates of Adjacent Segment Disease.
| PLF level | Total number of Patients | Patients who developed ASD |
|---|---|---|
| L2-L3 | 1 | 0 |
| L3-L4 | 16 | 2 (12.5%) |
| L4-L5 | 108 | 22 (20.4%) |
| L5-S1 | 8 | 1 (12.5%) |
Open in a separate window
*PLF = Posterolateral Lumbar Fusion; ASD=Adjacent Segment Disease; Group I=patients who had a single-level PLF with additional levels decompressed; Group II=patients underwent a single-level laminectomy and PLF; No correlation was seen between PLF level and the development of ASD (P=0.159, ρ=0.123).
AS Disease developed in 13 of 54 patients (24.1%) in the “adjacent-level” cohort. Of the 13 patients who developed AS Disease, four were treated conservatively with medications and physical therapy, six had epidural injections, and three underwent revision surgery extending the arthrodesis to the symptomatic level. The overall reoperation rate for AS Disease among patients in the “adjacent-level” cohort was 5.5% (3/54). Among the patients in the “same-level” cohort, 12 of 79 (15.2%) developed AS Disease. Of the 12 patients who developed AS Disease, one was treated with medications, five were treated with epidural injection, and six were treated with revision surgery. The overall reoperation rate for ASD among patients in the “same-level” cohort was 7.6% (6/79 patients) (Table 3) (Fig. 1, Fig. 2).
Table 3
Summary of treatment methods for each patient who developed Adjacent Segment Disease.
| Treatment | Group I | Group II | Total | P-value |
|---|---|---|---|---|
| Physical Therapy | 7.4% | 1.3% | 3.8% | 0.16 |
| Epidural Injections | 11.1% | 3.8% | 8.3% | 0.36 |
| Re-Operation | 5.5% | 7.6% | 6.8% | 0.74 |
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*PLF = Posterolateral Lumbar Fusion; ASD=Adjacent Segment Disease; Group I=patients who had a single-level PLF with additional levels decompressed; Group II=patients underwent a single-level laminectomy and PLF.
Fig. 1
Percentage of patients who developed Adjacent Segment Disease.
Fig. 2
Percentage of patients who underwent a reoperation for Adjacent Segment Disease.
There was neither a significantly higher incidence of AS Disease (P=0.26) nor reoperation rate (P=0.74) between the cohorts. Fisher's exact testing demonstrated no difference in developing AS Disease based on the level of arthrodesis (P=0.70) or the number of levels decompressed adjacent to the arthrodesis (P=0.23) (Table 4). Spearman's correlation coefficient demonstrated no significant correlations between the development of AS Disease and patient demographics like age (ρ=−0.11; P=0.2) or gender (ρ=−0.12; P=0.17). Also, patients with and without AS Disease demonstrated no significant differences with respect to age (P=0.21), gender (P=0.36), or level fused at index surgery (P=0.73). The estimated disease-free survival for the entire population at five years was approximately 85% (Fig. 3).
Table 4
Patients who underwent a multi-level decompression with a single level arthrodesis.
| Number of levels decompressed above/below the PLF | Number of patients who developed ASD | Number of patients asymptomatic at adjacent levels | Total patients |
|---|---|---|---|
| 1 | 5 (20%) | 17 | 22 (41%) |
| 2 | 7 (28%) | 17 | 24 (45%) |
| 3 | 1 (20%) | 3 | 4 (7%) |
| 4 | 0 (0%) | 4 | 4 (7%) |
| 5 | 0 (0%) | 0 | 0 (0%) |
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*PLF = Posterolateral Lumbar Fusion; ASD=Adjacent Segment Disease; No correlation was seen between the number of levels decompressed and the development of ASD (P=0.23).
Fig. 3
Kaplan Meier survivorship analysis.
4. Discussion
AS Disease is described as new onset clinical symptoms correlating with radiographic evidence of spinal canal or nerve root compression at a level adjacent to a previous arthrodesis construct. This pathology is considered a substantial source of morbidity among postoperative patients, with prior findings indicating that 16.5% of patients will develop AS Disease requiring additional surgery within five years after PLF.19 The presence of AS Disease after PLF can undoubtedly detract from the overall postoperative course, as Lai et al. demonstrated such patients are significantly less satisfied with their surgical outcome.24
In our study, we focused on delineating whether or not adjacent-level decompression in the setting of a single-level PLF was associated with an increased risk of developing AS Disease. While performing an isolated decompression on adjacent segments for associated stenosis is the preferred treatment strategy for many surgeons, skeptics highlight the destabilizing consequences of removing much of the posterior column adjacent to an arthrodesis construct. They argue that the potential destabilization, in conjunction with concerted mechanical stress above or below a fused segment, accelerates the degenerative process in patients already prone to disease. Supporting evidence by Sears et al. and Miyagia et al. has found that these patients are 2.4 times more likely to require reoperation and over five times more likely to develop AS Disease than patients who did not have an adjacent level decompression.26,27 However, there may be potentially confounding elements of the surgical treatment plan to account for when assessing adjacent decompression and the risk for AS Disease, as associations with other factors, such as fusion construct length, have been linked to the development of AS Degeneration and AS Disease.16,28 Notably, a meta-analysis performed by Zhang et al. identified fusion construct length as the most significant risk factor for developing AS Disease.28 Ultimately, surgeons are faced with a dilemma when treating patients with multi-level stenosis and single-level spondylolisthesis, as the literature has found that both operative strategies may accelerate the degenerative process leading to AS Disease.
The results of our study suggest that at midterm follow-up, performing an adjacent level posterior spinal decompression in the setting of a single-level PLF is not associated with the development of AS Disease. These results were consistent with several investigations in support of adjacent decompression. Matsumoto et al. demonstrated that performing an adjacent-level laminectomy predisposed patients to AS Degeneration, as measured by disc height, but did not predispose them to increased rates of AS Disease or reoperation.29 Additionally, our study did not find any demographic variables associated with the development of AS Disease despite previous reports highlighting increasing age, body mass index (BMI), adjacent level spondylosis, fusion technique, and sagittal balance as possible culprits.5,23
There were several limitations associated with this study. First, our findings are subject to all the inherent biases associated with a retrospective design. Second, the minimum follow-up was relatively short, as two years may not represent an adequate duration for AS Disease to develop. With that said, this is one of the first studies to evaluate single-level PLF in the setting of single or multi-level posterior decompression. As such, reporting midterm results represents an opportunity to assess the natural history of AS Disease in this population. Lastly, our study has a relatively small population size. While this undoubtedly represents an issue, our power analysis, which utilized a weighted rate of AS Disease of 10.4%, determined that we must include at least 32 patients in each group to achieve 80% power, assuming α=0.05, which we were able to accomplish.30, 31, 32, 33, 34, 35
In summary, this study suggests that patients who undergo an adjacent level lumbar decompression around a single-level arthrodesis for spondylolisthesis are not at increased risk of developing AS Disease when compared with patients undergoing decompression only at the stabilized segment. Therefore, it appears that stenotic levels above or below a spondylisthetic level may be safely decompressed without the need for an extension of the arthrodesis to include those levels. Further prospective long-term evaluations will be necessary to validate our findings.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Informed consent
Waiver of informed consent per institutional protocol.
Institutional ethical committee approval
Thomas Jefferson University IRB Approved.
Authors contributions
TP (methodology, data curation, formal analysis, writing – original draft, writing – review and editing), BJN (methodology, data curation, formal analysis, writing – review and editing), WC (methodology, data curation, formal analysis, writing – review and editing), PK (formal analysis, writing – review and editing), TWH (formal analysis, writing – review and editing), CKK (conceptualization, supervision, formal analysis, writing – review and editing), GDS (conceptualization, supervision, formal analysis, writing – review and editing), ARV (conceptualization, supervision, formal analysis, writing – review and editing), ASH (conceptualization, supervision, formal analysis, writing – review and editing).
Declaration of conflicting interests
The authors declare that there are no conflicts of interest.
Acknowledgements
None.
Footnotes
☆The authors and I have nothing relevant to disclose.
☆☆Research approved by the Thomas Jefferson University Institutional Review Board.
☆☆☆Research performed at The Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA.
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