Abstract
There is a debate regarding the distal fusion level for degenerative lumbar scoliosis. Whether a healthy L5-S1 motion segment should be included or not in the fusion remains controversial. The purpose of this study was to determine the optimal indication for the fusion to the sacrum, and to compare the results of distal fusion to L5 versus the sacrum in the long instrumented fusion for degenerative lumbar scoliosis. A total of 45 patients who had undergone long instrumentation and fusion for degenerative lumbar scoliosis were evaluated with a minimum 2 year follow-up. Twenty-four patients (mean age 63.6) underwent fusion to L5 and 21 patients (mean age 65.6) underwent fusion to the sacrum. Supplemental interbody fusion was performed in 12 patients in the L5 group and eleven patients in the sacrum group. The number of levels fused was 6.08 segments (range 4–8) in the L5 group and 6.09 (range 4–9) in the sacrum group. Intraoperative blood loss (2,754 ml versus 2,938 ml) and operative time (220 min versus 229 min) were similar in both groups. The Cobb angle changed from 24.7° before surgery to 6.8° after surgery in the L5 group, and from 22.8° to 7.7° in the sacrum group without statistical difference. Correction of lumbar lordosis was statistically better in the sacrum group (P = 0.03). Less correction of lumbar lordosis in the L5 group seemed to be associated with subsequent advanced L5-S1 disc degeneration. The change of coronal and sagittal imbalance was not different in both groups. Subsequent advanced L5-S1 disc degeneration occurred in 58% of the patients in the L5 group. Symptomatic adjacent segment disease at L5-S1 developed in five patients. Interestingly, the development of adjacent segment disease was not related to the preoperative grade of disc degeneration, which proved minimal degeneration in the five patients. In the L5 group, there were nine patients of complications at L5-S1 segment, including adjacent segment disease at L5-S1 and loosening of L5 screws. Seven of the nine patients showed preoperative sagittal imbalance and/or lumbar hypolordosis, which might be risk factors of complications at L5-S1. For the patients with sagittal imbalance and lumbar hypolordosis, L5-S1 should be included in the fusion even if L5-S1 disc was minimal degeneration.
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Aebi M (2005) The adult scoliosis. Eur Spine J 14:925–948. doi:10.1007/s00586-005-1053-9
Bridwell KH, Edwards CCII, Lenke LG (2003) The pros and cons to saving the L5–S1 motion segment in a long scoliosis fusion construct. Spine 28:S234–S242. doi:10.1097/01.BRS.0000092462.45111.27
Brown KM, Ludwig SC, Gelb DE (2004) Radiographic predictors of outcome after long fusion to L5 in adult scoliosis. J Spinal Disord Tech 17:358–366. doi:10.1097/01.bsd.0000112080.04960.67
Edwards CCII, Bridwell KH, Patel A, Rinella AS, Jung Kim Y, Berra AB, Della Rocca GJ, Lenke LG (2003) Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5–S1 disc. Spine 28:2122–2131. doi:10.1097/01.BRS.0000084266.37210.85
Edwards CCII, Bridwell KH, Patel A, Rinella AS, Berra A, Lenke LG (2004) Long adult deformity fusions to L5 and the sacrum. A matched cohort analysis. Spine 29:1996–2005. doi:10.1097/01.brs.0000138272.54896.33
Emami A, Deviren V, Berven S, Smith JA, Hu SS, Bradford DS (2002) Outcome and complications of long fusions to the sacrum in adult spine deformity. Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine 27:776–786. doi:10.1097/00007632-200204010-00017
Horton WC, Holt RT, Muldowny DS (1996) Controversy. Fusion of L5-S1 in adult scoliosis. Spine 21:2520–2522
Kim YJ, Bridwell KH, Lenke LG, Cho KJ, Edwards CCII, Rinella AS (2006) Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis. J Bone Joint Surg Am 88:721–728. doi:10.2106/JBJS.E.00550
Kostuik JP, Hall BB (1983) Spinal fusions to the sacrum in adults with scoliosis. Spine 8:489–500. doi:10.1097/00007632-198307000-00006
Kwon BK, Elgafy H, Keynan O, Fisher CG, Boyd MC, Paquette SJ, Dvorak MF (2006) Progressive junctional kyphosis at the caudal end of lumbar instrumented fusion: etiology, predictors, and treatment. Spine 31:1943–1951. doi:10.1097/01.brs.0000229258.83071.db
Polly DW Jr, Hamill CL, Bridwell KH (2006) Debate: to fuse or not to fuse to the sacrum, the fate of the L5-S1 disc. Spine 31:S179–S184. doi:10.1097/01.brs.0000234761.87368.ee
Weiner DK, Distell B, Studenski S, Martinez S, Lomasney L, Bongiorni D (1994) Does radiographic osteoarthritis correlate with flexibility of the lumbar spine? J Am Geriatr Soc 42:257–263
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Cho, KJ., Suk, SI., Park, SR. et al. Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis. Eur Spine J 18, 531–537 (2009). https://doi.org/10.1007/s00586-009-0883-2
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DOI: https://doi.org/10.1007/s00586-009-0883-2