Journal Reading

Risk factors for adjacent segment

degeneration after surgical correction of
degenerative lumbar scoliosis
Keeyong Ha, JongMin Son, JinHyung Im, InSoo Oh
Presented by:
Setia Wati Astri Arifin
Resident of Medical Rehabilitation Department
Supervised by:
dr. N. Diana Yulisa, SpRad(K)

Introduction

Study
Subjects
Material &
Methods

98 patients
Underwent surgical
correction and
lumbar/thoracolum
bar fusions with
pedicle screw
instrumentation for
DLS
Aug 2003 to Dec
2005

To assess the risk factors of

occurrence of radiographic ASD,
this study evaluated
the
correlation between:

Inclusion
Criterias
Age > 18 y.o. at the time of
surgery
With at least one of the
defined radiographic ASD
criteria

Exclusion
Criterias
Diagnosis of scoliosis with
other etiology

Idiopathic,
paralytic/neuromuscular, or
congenital etiology

Age < 18 y.o. at the time of

surgery

Inclusion
Criterias
Age > 18 y.o. at the time of
surgery
With at least one of the
defined radiographic ASD
criteria

Radiographic
ASD

Translation greater than 4

mm, angular change
greater than 10
Severe collapse of
intervertebral disc space
Herniated nucleus
pulposus and stenosis
Vertebral compression
fracture
Pedicle screw loosening
and nonunion

Translation > 4
mm

Angular change >

10

Severe collapse of
intervertebral disc space

Herniated nucleus
pulposus &
stenosis

Vertebral
compression
fracture

Pedicle screw
loosening & broken
pedicle screws

Material &
Methods

The pe

Resul
The ts

statistically
significant
parameters
that were
related to ASD
occurrence
were:
Age
Disc
degeneration
on MRI
(cephalad
and caudal
disc)

From the multivariate analysis, there were no statistically

significant differences between age, cephalad disc and
caudal disc as prognostic factors for survival in patients with
ASD after surgery

KaplanMeier survivorship
analysis

Factors
The
There
mean
were
that
ODI
VAS
were
improved
improved
relatedfrom
from
to ASD
65.3
7.8 occurrence
preoperatively
preoperatively
wereto
to
preoperative
4.6
48.6
at at
the
the
la

Resul
ts

Discussion
ASD is a debatable late complication of spinal fusion

The Risk Factors of ASD

1.
2.
3.
4.
5.
6.
7.
8.

Old age
Female gender
High BMI
Osteoporosis
Rigid fusion such as PLIF and pedicular screw system
Fusion length
Sagittal malalignment
Preexisting adjacent level degeneration

Cheh

Limitations
The limitations of this study are:
1. The relatively short duration of followup
2. Not taking into consideration the scoliotic cu
rve type and sagittal imbalance.
3. The number of patients was limited
4. Retrospective nature
5. Not a randomized controlled design

Conclusion
The presence of disc deg
eneration and age greate
r than 65 years seem to b
e the most significant risk
factors for ASD after surg
ical correction of DLS and
should be primarily consi
dered before recommend
ing spinal fusions

Further investigations wi
th respect to determinat
ion of the importance of
the individual risk factor
s, particularly risk factor
s that are modifiable, ar
e required to reduce the
development of ASD

Ad maiorem Dei gloriam inque hominum salutem

Cobbs Angle

The Cobb Angle helps a doctor to determine what type of treatment is nec
essary.
A Cobb Angle of 10 degrees

Between 15 and 20 degrees:

Not require any specific treatment, regular check-ups, physical therapy contains exercise ses
sions, home exercise program

Between 20 and 40 degrees

Regarded as a minimum angulation to define Scoliosis

Brace to keep the spine from developing more of a curve, scoliosis intensive rehabilitation p
rogram is necessary (3-5x/week)

40 50 degrees or more:

Surgery to correct the curve, a frequent recurring procedure is the spinal fusion, to link th
e vertebrae together so that the spine cannot longer continue to curve.

Sagittal Spinal Parameters

Geometrical measurements relating to spinal curv
atures were obtained from following parameters:
Thoracic kyphosis (TK)
The angle measured from the upper endplate of T4 to
the lower endplate of T12

Lumbar lordosis (LL)

The angle measured from the upper endplate of L1 to t
he upper endplate of S1

Previous studies have shown good reliability for ra

diographic evaluation of spinal curvatures
Todd et al. Journal of Orthopaedic Surgery and Research (2015) 10:162

Sagittal Vertical Axis (SVA)

Sagittal Vertical Axis (SVA)
Defined by using the C7 plumb li
ne that intersects the superior co
rner of the upper sacral endplate
Measured and recorded in centi
meter
The sagittal vertical axis assesses i
f an individual is in neutral, positi
ve or negative alignment by com
paring the head position relative
to the sacral promontory
Todd et al. Journal of Orthopaedic Surgery and Research (2015) 10:162

Sagittal Pelvic Parameters

Geometrical measurements relating to the pelvic paramet

ers were measured and recorded in degrees

Pelvic incidence (PI)

Pelvic tilt (PT)

http://www.scielo.br/img/revistas/aob/v22n4//1413-7852aob-22-04-00179-gf01.jpg

Geometrical relationship
PI = PT + SS

Todd et al. Journal of Orthopaedic Surgery and Research (2015) 10:162

A morphological parameter and is the angle measure

d from a perpendicular line to the mid-point of the sa
cral plate and extended to the centre of the femoral
head
A positional parameter and is the angle measured fro
m a perpendicular line starting at the centre of the fe
moral head and extended to the mid-point of the sac
ral plate

Sacral slope (SS)

A positional parameter and is the angle measured fro

m the superior endplate of S1 and a horizontal axis

Spinal Curvatures
Four types of spinal curvatures correlatin
g to the angle of the sacral slope were d
efined according to Roussouly et al.
Type I:
Low sacral slope <35 with an 80:20 thorac
olumbar curve.

Type II:
Low sacral slope <35 with a 60:40 thoracol
umbar flat back.

Type III:
Sacral slope >35 <45 with a 50:50 thorac
olumbar curve.

Type IV:
High sacral slope >45 with a 20:80 reverse
d thoracolumbar curve
Todd et al. Journal of Orthopaedic Surgery and Research (2015) 10:162

Intercristal Line
An imaginary line draw
n in the horizontal plan
e at the upper margin
of the iliac crests
Locates the level of the
L4 vertebra
A useful landmark in sp
inal tap procedure

http://www.mif-ua.com/frmtext/Trauma/2012/2-132012/158/158.jpg

The lines referred to in the study: the

palpated intercristal line (a), the
imaged intercristal line (b) and the
palpated posterior superior iliac
spine line (c).
http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/anatomytables/topogr_abdomen.html

Oswestry Disability Ind

ex
(ODI)

Oswestry Disability
Index
(ODI)

Pfirrman Classification of Disc Degeneration

http://synapse.koreamed.org/ArticleImage/0168ASJ/asj-8-813-i001-l.jpg