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Spinal Deformities in Adolescents, Adults and Older Adults
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Chapter 3
An Anatomical and Pathological
Classification of Thoracolumbar
Adjacent Segment Disease
David ChristopherKieser and NielsHammer
Ab
stract
Structural failure of the spine adjacent to the level of a previous spinal fusion
is commonly observed. It may be defined by the radiologic degree of adjacent
deformity, often termed junctional level kyphosis, proximal junctional kyphosis or
junctional level failure, or the symptomatic failure of the spine above the level of
an operation, termed adjacent segment disease (ASD). ASD can be further specified according to its anatomical location of failure, which provides insight into the
specific pathological cause of failure and the optimal subsequent management. This
chapter describes the anatomical and pathological classification of ASD in order to
help clinicians understand the cause of failure and thereby reduce its rate and offer
a treatment algorithm if it occurs.
Keywords: adjacent segment disease, thoraco-lumbar fusion, pathological cause,
junctional level kyphosis
. Introduction
Adjacent segment disease (ASD) is the symptomatic structural failure of the spine
or sacrum adjacent to an area of previous operative intervention, most notably fusion
[1]. Internationally, the numbers of spinal fusions being performed is increasing.
Within the USA approximately 457,500 adult spinal fusions and 38,000 paediatric
spinal deformity corrections are performed annually, with similar rates per capita
reported worldwide [2]. Of concern is that more than 20% of patients undergoing
lumbar deformity surgery will develop ASD within 8years, most of which occurs
early with 40% requiring revision within 6months [3–9]. This has a significant clinical effect on patient outcomes, with pain, neurological, emotional, social and occupational concerns, but also carries a large financial burden, with an estimated cost in the
USA for revision being $77,432 USD per patient [10, 11]. This would suggest that over
500 million USD is spent annually on the surgical treatment of ASD.Yet, a complete
understanding of the aetiology of this problem has not been compiled.
It is believed that the cause of ASD is multifactorial [12]. These causes can be
separated into non-modifiable, potentially modifiable and modifiable risk factors.
Non-modifiable risk factors include patient age and expected baseline motion
segment degeneration that cannot be modified with current known treatments
[13, 14]. These factors are particularly pertinent in the adult population where
their index procedure is often related to degeneration which itself renders patients
at higher risk of degeneration at other levels.
Spinal Deformities in Adolescents, Adults and Older Adults
Potentially modifiable risk factors include bone density, which may be amenable
to medical treatment [15]. Others include fusion without instrumentation and
limiting the fusion length, however the pathology often dictates the length of fusion
and implant requirement [13, 16].
Modifiable risk factors include intraoperative surgical techniques, notably
motion preservation to reduce the adjacent segment load, avoiding circumferential
fusion of the most cranial segment that increases the stresses on the adjacent level,
ensuring spinal balance, avoiding extensor musculature and ligamentous damage,
protecting the adjacent facets, endplates and intervertebral disc (IVD) [13, 14].
While multiple classification systems and definitions have been proposed, none
have attempted to group these into anatomical or pathological considerations. Our
classification broadly categorises ASD into five groups according to the anatomical
region of failure which can then determine the likely pathological cause and offer
treatment direction.
. The Kieser and Hammer classification system
. Type : global failure (implant pull-out)
This form of ASD is seen when metalware pulls out of the vertebrae (Figure ).
This failure is not seen in anterior interbody constructs, unless supplementary
posterior or lateral instrumentation is utilised. This is because it is recognised as
persistent spinal malalignment, which requires interconnected rigid implants to
remain in one position and the spine to displace from the rigid instrumentation.
However, with lateral implants (plates, stapes, etc.) and a failure to restore coronal
balance or posterior implants and a failure to restore sagittal balance, the metalware
can pull out of the bone producing a type 1 failure.
This failure is therefore almost always due to malalignment, but can be subclassified into:
1a. Bone failure: osteoporosis.
1b. Implant failure: insufficient fixation.
1c. Combination.
In type 1a, the bone quality is insufficient to hold the implanted device in a
given configuration, with the effect that the metalware pulls out. Similarly, in type
1b the implant configuration is insufficient to stabilise and anchor in the bone and
Figure 1.
Type 1 (global failure).
An Anatomical and Pathological Classification of Thoracolumbar Adjacent Segment Disease
DOI: http://dx.doi.org/10.5772/intechopen.89960
Figure 2.
Antero-posterior X-rays of a patient with a previous L4-S1 fusion who developed type 4d ASD of L3/4 causing
foraminal stenosis and therefore underwent a lateral interbody fixation and plate (a. immediate postoperative)
but with failure to completely restore coronal balance and insufficient fixation resulting in implant pullout and progressive coronal imbalance with recurrence of symptomatic foraminal stenosis (b. 6weeks
postoperative). Therefore supplementary percutaneous pedicle screw insertion to augment fixation and bracing
was undertaken, which resulted in sufficient fixation to permit definitive fusion (c. 6months postoperative).
therefore it pulls out (Figure ). In most cases it is a combination of both poor bone
stock and insufficient implant fixation.
In an asymptomatic patient without skin compromise, the practitioner or surgeon advises bracing to prevent further progression until the fusion has developed.
In contrast, in symptomatic patients or those with progressive failure amendable
to operative intervention, the treatment of type 1 failure is revision surgery with
restoration of spinal alignment and supplementary bracing until fusion has developed. In addition, for each sub-classification we advocate.
1a. Bone supplementation with medical management of osteoporosis (e.g. cal-
cium, vitamin D, bisphosphonates, etc.) and increased fixation (e.g. cemented
screws, HA coated screws, sublaminar bands, etc.).
1b. Increase fixation of the operative levels. May require extension of fusion if
adequate fixation of the operative levels is not possible.
1c. Both.
It should be recognised that bone supplementation takes a prolonged period
of time to achieve clinical benefit and most of these patients require semi-urgent
surgical intervention. Thus, in symptomatic patients with deficient bone quality,
increased fixation should be provided in addition to the medical management of
osteoporosis. Furthermore, bracing should be considered to supplement the spinal
stability provided by the surgery until fusion has occurred.
. Type : adjacent bone failure (failure of the cranial or caudal
uninstrumented vertebrae)
This form of ASD occurs when an adjacent, uninstrumented vertebrae fails, typically with a compression type fracture (Figures and ). This is most commonly
caused by poor bone quality and/or malalignment and is therefore subclassified as:
Spinal Deformities in Adolescents, Adults and Older Adults
2a. Poor bone stock.
2b. Malalignment.
2c. Combination.
Most patients have a combination of malalignment and osteoporosis but are predominantly affected by their poor bone quality. Unlike type 1 failures, these patients
are rarely in need of an urgent surgical intervention. Therefore, a conservative
approach can be initially trialled. Bracing as well as vertebroplasty or kyphoplasty
should be considered to avoid progressive collapse and deformity. However, the
clinician should recognise that vertebral body cementation may affect subsequent
extension of fusion if necessitated, particularly if pedicle screws are considered
necessary. Therefore, surgeons treating these patients should consider alternative
fixation techniques, such as cortical trajectory screws, in the cemented vertebrae if
extension is subsequently required. In those that become asymptomatic these fractures should be treated as osteoporotic compression fractures. In those that remain
symptomatic and are amenable to operative intervention, the treatment should be:
2a. Bone supplementation±bracing until fracture union is achieved. In a
globally aligned spine with union of the fracture, no operative intervention is
required.
2b. Deformity correction with extension of fusion and increased fixation.
Increased fixation is necessary because the bone has shown evidence of weak-
ness, even in the absence of global osteoporosis, and therefore increased fixation
is necessitated.
2c. a±b: Bone supplementation and bracing if the global malalignment is
acceptable OR bone supplementation and deformity correction with extension
of fusion, increased fixation and bracing if the malalignment is unacceptable.
. Type : endplate failure
This is one of the most common forms of ASD and it occurs when the most
cranial instrumented vertebral body collapses (Figures and ). It can occur with
posterior or anterior/lateral implants and its causes can be classified as:
3a. Poor bone stock.
3b. Devascularisation of the endplate.
3c. Excessive endplate load.
3d. Combination.
Figure 3.
Type 2 (adjacent bone failure).
An Anatomical and Pathological Classification of Thoracolumbar Adjacent Segment Disease
DOI: http://dx.doi.org/10.5772/intechopen.89960
Figure 4.
A lateral standing full spine x-ray of a patient who had undergone an L2-S1 fusion with a failure to correct
sagittal balance who developed an adjacent compression fracture of L1 that accentuated the spinal imbalance
and over a 6-year period, despite attempted compensation with pelvic retrolisthesis and thoracic hypokyphosis,
they developed a progressive anterolisthesis of T11/12 causing thoracic myelopathy.
Figure 5.
Type 3 failure (endplate failure).
Spinal Deformities in Adolescents, Adults and Older Adults
Figure 6.
Lateral standing X-rays of an obese osteoporotic patient who had previously undergone an L4/5
circumferential fusion complicated by global sagittal imbalance, pedicle screw malposition causing right
L5 radiculopathy and dysfunction as well as progressive type 4d ASD of L3/4 causing critical central
stenosis (a). They underwent revision of their instrumentation with L3-S2 fusion and correction of their
sagittal balance, supplemented with cranial vertebroplasty (b). However, the patient developed type 3d
ASD (c).
Most are thought to occur because of poor bone stock and therefore mimic
osteoporotic compression fractures. However, end-plate devascularisation,
either from a direct injury to the end arteries of the endplate by subcortical
screws or by damage of the nutrient vessels to the endplate by anterior dissection
can occur [17]. Similarly, with interbody devices the excessive load induced by
rigid constructs can surpass the endplates’ biomechanical tolerance and induce
fracture.
Treatment depends on the severity of symptoms and the degree of compression
of the vertebrae. In asymptomatic patients bracing to prevent further compression
and bone supplementation may need to be considered if there is poor bone stock.
In symptomatic patients amendable to operative intervention, treatment should
consist of:
3a. Treat as osteoporotic compression fractures. Bone supplementation±brac-
ing. If metalware protrudes into the adjacent IVD consider deformity correction
with increased fixation.
3b. Bracing. If metalware protrudes into adjacent IVD consider deformity
correction. While the cause is endplate vascular compromise, there is to date no
evidence that changing the surgical technique for the extension of fusion will
reduce the risk, however surgeons should consider avoidance of cranial endplate
compromise if possible (e.g. cortical trajectory screws, sublaminar bands or
hooks).
3c. Deformity correction with extension of fusion and avoidance of a rigid
interbody device at the most cranial fusion level.
3d. Treat as osteoporotic compression fractures. Bone supplementation±brac-
ing. If metalware protrudes into adjacent IVD consider deformity correction
with extension of fusion and avoidance of both cranial endplate compromise
and a rigid interbody device at the most cranial fusion level.
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