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      Therapeutics and Clinical Risk Management (submit here)

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      Repeated adjacent segment diseases and fractures in osteoporotic patients: a case report


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          Pedicle screw instrumentation for treating spinal disorder is becoming increasingly widespread. Many studies have advocated its use to facilitate rigid fixation for spine; however, adjacent segmental disease is a known complication. Instrumented fusion for osteoporotic spines remains a significant challenge for spine surgeons. Prophylactic vertebroplasty for adjacent vertebra has been reported to reduce the complications of junctional compression fractures but has raised a new problem of vertebral subluxation. This case report is a rare and an extreme example with many surgical complications caused by repeated instrumented fusion for osteoporotic spine in a single patient. This patient had various complications including adjacent segmental disease, vertebral subluxation, and junctional fractures on radiographs and magnetic resonance images.

          Case presentation

          An 81-year-old Taiwanese woman underwent decompression and instrumented fusion of L4-L5 in Taiwan 10 years ago. Due to degenerative spinal stenosis of L3-L4 and L2-L3, she had decompression with instrumented fusion from L5 to L1 at the previous hospital. However, catastrophic vertebral subluxations with severe neurologic compromise occurred, and she underwent salvage surgeries twice with prolonged instrumented fusion from L5 to T2. The surgeries did not resolve her problems of spinal instability and neurologic complications. Eventually, the patient remained with a Frankel Grade C spinal cord injury.


          Adjacent segmental disease, junctional fracture, and vertebral subluxation are familiar complications following instrumented spinal fusion surgeries for osteoporotic spines. Neurologic injuries following long instrumentation are often serious and difficult to address with surgery alone. Conservative treatments should always be contemplated as an alternative method for patients with poor bone stock.

          Most cited references16

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          Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature.

          Review of the literature. Review the definition, etiology, incidence, and risk factors associated with as well as potential treatment options. The development of pathology at the mobile segment next to a lumbar or lumbosacral spinal fusion has been termed adjacent segment disease. Initially reported to occur rarely, it is now considered a potential late complication of spinal fusion that can necessitate further surgical intervention and adversely affect outcomes. MEDLINE literature search. The most common abnormal finding at the adjacent segment is disc degeneration. Biomechanical changes consisting of increased intradiscal pressure, increased facet loading, and increased mobility occur after fusion and have been implicated in causing adjacent segment disease. Progressive spinal degeneration with age is also thought to be a major contributor. From a radiographic standpoint, reported incidence during average postoperative follow-up observation ranging from 36 to 369 months varies substantially from 5.2 to 100%. Incidence of symptomatic adjacent segment disease is lower, however, ranging from 5.2 to 18.5% during 44.8 to 164 months of follow-up observation. The rate of symptomatic adjacent segment disease is higher in patients with transpedicular instrumentation (12.2-18.5%) compared with patients fused with other forms of instrumentation or with no instrumentation (5.2-5.6%). Potential risk factors include instrumentation, fusion length, sagittal malalignment, facet injury, age, and pre-existing degenerative changes. Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common but does not correlate with functional outcomes. Potentially modifiable risk factors for the development of adjacent segment disease include fusion without instrumentation, protecting the facet joint of the adjacent segment during placement of pedicle screws,fusion length, and sagittal balance. Surgical management, when indicated, consists of decompression of neural elements and extension of fusion. Outcomes after surgery, however, are modest.
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            Adjacent segment disease followinglumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up.

            Retrospective radiographic outcomes analysis. We had 3 hypotheses: 1) a longer fusion; 2) a more proximal instrumented vertebra, and 3) circumferential fusion versus posterior-only fusion would increase the likelihood of adjacent segment disease (ASD). The literature analyzing risk factors, prevalence, and presentation of patients with ASD is varied and without clear consensus. A total of 188 patients with minimum 5-year follow-up who had lumbar/thoracolumbar fusion with pedicle screw instrumentation for degenerative disorders were included. Radiographic ASD was defined by: 1) development of spondylolisthesis >4 mm, 2) segmental kyphosis >10 degrees , 3) complete collapse of disc space, or 4) more than 2 grades worsening of Weiner classification. Clinical ASD was defined as 1) symptomatic spinal stenosis, 2) intractable back pain, or 3) subsequent sagittal or coronal imbalance. Radiographic ASD occurred in 42.6% (80 of 188) of patients. Patients with radiographic ASD had worse Oswestry scores (20.3 vs. 12.5; P = 0.001) at ultimate follow-up than those without ASD. Clinical ASD developed in 30.3% (57 of 188) of patients. Clinical ASD manifested as spinal stenosis (n = 47), instability-type back pain (n = 5), and sagittal or coronal imbalance (n = 5). Age at surgery over 50 years and length of fusion were significant risk factors for the development of ASD in the lumbar spine. Fusion to L1-L3 proximally increased the risk of ASD when compared with L4 and L5. Circumferential fusion versus posterior fusion was not a significant factor in the development of ASD. Patients over the age of 50 were at higher risk of developing clinical ASD than those 50 years old or younger. Length of fusion was a significant risk factor in the development of ASD in the lumbar spine. Fusion up to L1-L3 increased the risk of ASD when compared with L4 and L5. Circumferential fusion, as opposed to posterolateral fusion, was not a statistically significant risk factor for the development of ASD.
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              Risk factors of adjacent segment disease requiring surgery after lumbar spinal fusion: comparison of posterior lumbar interbody fusion and posterolateral fusion.

              A retrospective study.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                28 July 2016
                : 12
                : 1145-1150
                [1 ]Department of Orthopedic Surgery, Changhua Christian Hospital, Changhua City
                [2 ]Liberal Arts Center of Da Yeh University, Dacun Township, Changhua County, Taiwan
                [3 ]Department of Clinical Image, Changhua Christian Hospital, Changhua City, Changhua County, Taiwan
                Author notes
                Correspondence: Chiu-Liang Chen, Department of Orthopedic Surgery, Changhua Christian Hospital, 135 Nanxiao Street, Changhua City, Changhua County 500, Taiwan, Tel +886 47 116 128, Fax +886 47 116 129, Email 111111@ 123456cch.org.tw
                © 2016 Chen et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Case Report

                osteoporotic spine,vertebral subluxation,junctional fracture,instrumented fusion,complication


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