Adjacent segment disease

Definition
• Presentation of new symptoms referable to adjacent
level ( above or below ) after pt have undergone
successful treatment of a spinal problem at the index
level

• Degeneration is asymptomatic radiological process

• ASD can be clinical > radiological symptomatic process

• Possibility that new disease will develop at an adjacent

level over the long term.
Lumbar spine
 Pathophysiology
• Blood supply to adjacent disc changes
• Accelerates the disc degeneration which
should have occurred other wise also
• Its not a complication
• It’s a process – Natural history
Natural history of multilevel spondylosis
 Aging of spine – natural history
• Decrease in lumbar lordosis
• Forward shifting – positive sagittal imbalance
• There may be no back pain/ leg pain
• So most important risk factor is AGE
 Risk factors
• Surgery related • Non modifiable
1. Long fusion
2. Spinopelvic mismatch
1. Old age
3. Sagittal imbalance 2. Gender
4. Fusion > decompression • Modifiable
5. Distraction after PLIF
6. Ending fusion at L5 1. Osteoporosis
7. Iatrogenic muscle / facet 2. Obesity
damage
8. Laminectomy adjacent to fusion 3. Inactivity
9. PLIF > PLF >ALIF 4. Smoking
10. Floating fusion ( L4-L5 > L4-S1 )
• Pre op radiographic
indicators
1. Pre op adjacent
segment degeneration
2. Pre op facet
degeneration
3. Facet tropism
Types of ASD
1. Retrolisthesis
2. Adjacent #
3. Supra adjacent #
4. Kyphosis
5. Scoliosis
6. Translation
7. Loss of lordosis
8. Sagittal imbalance
9. Pseudoarthosis
10. Hallo loosening sign
11. Stenosis in adjacent segment
12. Facet degeneration
 Influence of spinal fusion
• Accelerates Adj Seg Deg ( Decreased disc
height and progression on pfirmann’s grade )
• Not clinically relevant ( unchanged ODI )

Mannion, A. F., Leivseth, G., Brox, J.-I., Fritzell, P., Hägg, O., & Fairbank, J. C. T.
(2014). ISSLS Prize Winner. Spine, 39(17), 1373–1383.
 Decompression in a fusion
• Full laminectomy > hemi-laminectomy
• 50% facets – Segmental hyper mobility
• 75% facets – Rotational instability

Relation between laminectomy and development of adjacent segment instability after

lumbar fusion with pedicle fixation.
Lai PL1, Chen LH, Niu CC, Fu TS, Chen WJ.
 Annual incidence after fusion
• Single level – 1.7%
• Two level – 3.2 %
• >2 level – 5 %
• Adjacent level laminectomy – 2.4 times
• Stopping at L5 – 1.7 times ( L5-S1 )

Adjacent segment disease in the lumbar spine following different treatment

interventions.
Radcliff KE1, Kepler CK, Jakoi A, Sidhu GS, Rihn J, Vaccaro AR, Albert TJ, Hilibrand AS.
Radiographic criteria
 Methods to decrease ASD
1. proper sagittal balance
2. Optimal disc space distraction while doing
interbody
3. Preservation of adjacent posterior elements
– MIS
4. Motion preserving technologies
( Arthroplasty/ Dynamic stabilization )