Abstract
Introduction
There is controversy regarding the appropriate proximal fusion level for adult degenerative scoliosis. Ideally, the horizontal vertebra is chosen for the upper instrumented vertebra to create a balanced spine. Fusion to T10 is recommended to prevent junctional problems at the proximal adjacent segment. The purpose of this retrospective study was to determine the optimal proximal fusion level for adult degenerative lumbar scoliosis.
Materials and Methods
Fifty-one patients with adult degenerative lumbar scoliosis (mean age 64.6 years) who underwent posterior instrumentation were analyzed after a minimum 2-year follow-up. The average number of levels fused was 5.9 segments (range 3–9) with distal fusion at L5 in 30 patients and S1 in 21 patients. The upper instrumented vertebra (UIV) ranged from T9 to L2. According to the relationship between UIV, horizontal vertebra (HV) and upper end vertebra (UEV), the patients were divided into three groups in the coronal plane: Group HV (UIV = HV or above); Group HV–UEV (UIV = between HV and UEV); and Group UEV (UIV = UEV or below). In the sagittal plane; the patients were divided into Group T9–10 (UIV = T9–10), Group T11–12 and Group L1–2.
Results
Proximal adjacent segment disease (ASD) was identified in 13 (25 %) out of 51 patients, including junctional kyphosis (n = 5), compression fractures (n = 4), progression of disc wedging (n = 2) and spinal stenosis (n = 2). Group UEV had more ASD (9 of 16 patients) compared to Group HV (2 of 21 patients) and Group HV–UEV (2 of 14 patients). It appeared that neutral vertebra could be a criterion for the selection of UIV in the coronal plane. Among the groups divided in the sagittal plane, proximal ASD was found in 47 % of 19 patients in Group L1–2, which was notably higher than 9 % in Group T9–10 and 20 % in Group T11–12.
Conclusions
Proximal adjacent segment disease developed more commonly when the proximal fusion stopped at the UEV or below in adult degenerative lumbar scoliosis. UIV must be above UEV in the coronal plane. Fusion to T11 or T12 was acceptable when UIV was above UEV, since there was no significant difference in the rate of proximal adjacent segment between fusion to T10 and fusion to T11 or T12.
Similar content being viewed by others
References
Shufflebarger H, Suk SI, Mardjetko S (2006) Debate: determining the upper instrumented vertebra in the management of adult degenerative scoliosis: stopping at T10 versus L1. Spine 31((19S)):S185–S194
Simmons ED (2001) Surgical treatment of patients with lumbar spinal stenosis with associated scoliosis. Clin Orthop Relat Res 384:45–53
Mok JM, Hu SS (2007) Surgical strategies and choosing levels for spinal deformity: how high, how low, front and back. Neurosurg Clin N Am 18(2):329–337
Yang SH, Chen PQ (2003) Proximal kyphosis after short posterior fusion for thoracolumbar scoliosis. Clin Orthop Relat Res 411:152–158
Grubb SA, Lipscomb HJ, Suh PB (1994) Results of surgical treatment of painful adult scoliosis. Spine 19(14):1619–1627
Cho KJ, Suk SI, Park SR et al (2008) Short fusion versus long fusion for degenerative lumbar scoliosis. Eur Spine J 17(5):650–656
Cho KJ, Suk SI, Park SR et al (2009) Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis. Eur Spine J 18(4):531–537
Le Huec JC, Aunoble S, Philippe L, Nicolas P (2011) Pelvic parameters: origin and significance. Eur Spine J 20(Supp 5):S564–S571
Cho KJ, Suk SI, Park SR et al (2010) Risk factors of sagittal decompensation after long posterior instrumentation and fusion for degenerative lumbar scoliosis. Spine 35(17):1595–1601
de Vries AA, Mullender MG, Pluymakers WJ et al (2010) Spinal decompensation in degenerative lumbar scoliosis. Eur Spine J 19(9):1540–1544
Cho KJ, Suk SI, Park SR et al (2007) Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis. Spine 32(20):2232–2237
Aebi M (2005) The adult scoliosis. Eur Spine J 14(10):925–948
Transfeldt EE, Topp M, Mehbod AA, Winter RB (2010) Surgical outcomes of decompression, decompression with limited fusion, and decompression with full curve fusion for degenerative scoliosis with radiculopathy. Spine 35(20):1872–1875
Gupta MC (2003) Degenerative scoliosis. Options for surgical management. Orthop Clin North Am 34(2):269–279
Kim YJ, Bridwell KH, Lenke LG, Rhim SC, Kim YW et al (2007) Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1? Spine 32(24):2653–2661
Glattes RC, Bridwell KH, Lenke LG et al (2005) Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine 30(14):1643–1649
Kim YJ, Bridwell KH, Lenke LG et al (2008) Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine 33(20):2179–2184
Lee GA, Betz RR, Clements DH, Huss GK (1999) Proximal kyphosis after posterior spinal fusion in patients with idiopathic scoliosis. Spine 24(8):795–799
Conflict of interest
None of the authors has any potential conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Cho, KJ., Suk, SI., Park, SR. et al. Selection of proximal fusion level for adult degenerative lumbar scoliosis. Eur Spine J 22, 394–401 (2013). https://doi.org/10.1007/s00586-012-2527-1
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00586-012-2527-1