ADJACENT

SEGMENT
DISEASE
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INTRODUCTION
Adjacent segment disease (ASD) is the name given to the development of alterations due to overload on
segments above or below a fused vertebral segment

ASD can present after various vertebral segment surgeries:

● Discectomy
● Arthrodesis
● Disc replacement There has been a long debate as to whether

Patient or surgical factors increase the risk of ASD: ASD is caused by surgery or is the product

● Facet degeneration of the natural evolution of the degenerative

● Age process

● Sagittal imbalance
● Long arthrodesis
 CERVICAL ADJACENT SEGMENT DISEASE
Congenital fused segment is less frequent than in a segment that has undergone surgical arthrodesis

MRI of cervical spine, T2- MRI of cervical spine, T2-

Lateral X-ray of cervical spine weighted sequence, sagittal Lateral X-ray of cervical spine weighted sequence, sagittal
section section
CLINICAL ASPECTS
Forms of Presentation

● Axial pain
Most frequent, located in the midline or paravertebral line, frequently
located in the posterior area of the skull base and in the medial region
of the scapular girdle
● Radicular pain
Less frequent, can present with radiation of insidious onset, generally
irritating and with predominance of paresthesia
● Spinal cord pain
present in upper and lower limbs and is not associated with a clear
radicular area, less burning sensation of pain, accompanied by a motor
Anterior and lateral X-rays of the
function condition cervical spine
● Myelopathy
● A combination of symptoms
 PHYSICAL EXAMINATION
● Reduced mobility
● Lateral tilt is limited at an early stage, followed by rotation and flexion extension.
● Stiffness, muscle spasm, hypertonia
● Fine motor function of the hand may be impeded, gait disorders, claudication or instability
● Upper limb muscle atrophy, radicular or spinal cord compression.
● Local pain, paravertebral contracture, hypotonia and hypotrophy.
● Joint stiffness
● Radicular compression (hypostasis, decreased muscle strength and areflexia)
● Spinal cord compression (hypertonia, hyperreflexia, clonus, babinski’s sign, alterations of superficial
abdominal reflexes)
 RADIOGRAPHY
Discovertebral degeneration in lateral X-rays:
● Disc impingement
● Endplate irregularity and sclerosis
● Osteophytosis
● Empty disc space

Facet degeneration in oblique X-rays:

● Impingement
● Sclerosis
● Hypertrophy Notable sclerosis is visible at the
level over the congenital block
● Subluxation (lateral X- ray)
 Algorithm for the
management of a patient
with cervical ASD
TREATMENT
Medical

● NSAIs are recommended, although corticoids, opiates, muscle relaxants, antidepressants and vitamin complexes
● Kinesiology and physiotherapy are useful and help to improve the clinical picture
● Braces : cervical collar may be useful for a short period of time, no longer than one month
● Blocks : can be foraminal or facetary
TREATMENT
Surgical

● Anterior approach
 Central or posterolateral hard disc herniation with radiculopathy
 Stenosis with negative spinous process line
 Spinal cord compression which could be resolved by decompression and anterior arthrodesis or a disc
prosthesis
● Posterior approach
 Indicated when spinal cord decompression or realignment without balance correction is required
 A laminoplasty or laminectomy can be performed
● Combined approach
 If the reason for the addition is instability with deformity or fixed deformity with compression
 LUMBAR ADJACENT SEGMENT DISEASE
More frequent at the cephalic level than at the distal level

The following factors have been suggested to increase the

risk of lumbar ASD:
● Instrumented surgery
● Pedicle instrumentation
● Long fixations
● 360° fusion
● Loss of balance
● Facet injury
● Previous degeneration of adjacent levels Signs of disc space deterioration
and L4-L5
● Age
● Osteoporosis and post-menopausal state
● Association of decompression procedures
CLINICAL ASPECTS
Forms of Presentation

● Axial pain
This pain is the most frequent and is located in the midline or
paravertebral
line of the lumbar region
● Radicular pain
Gait Claudication, Paresthesia
● Pain due fractures
the location will depend on whether there is a collapse at the cephalic
level of the arthrodesis or a sacrum fracture in the lumbosacral fusion
MRI of lumbosacral spine,
T2-weighted sequence, sagittal section
 PHYSICAL EXAMINATION
● Palpation of the spinous processes
Local pain, reveal paravertebral contracture, hypotrophy, reduced mobility
● Local kyphosis may be encountered

RADIOGRAPHY
● Facet degeneration changes in oblique X-rays
● Reveal monoaxial segment instability
● Lateral x-rays associated with ASD such as:
 Disc impingement
 Endplate irregularity and sclerosis Serious impingement is visible
at L3-L4 with local kyphosis
 Osteophytosis
(Lateral X-Rays)
 Empty disc space
 Algorithm for the
management of a patient
with lumbar ASD
TREATMENT
Medical

● Traumatic collapse : Initial rest, cross brace, a Jewett, Knight or TSLO brace
● Vertebral cementing : vertebroplasty, kyphoplasty or stentoplasty
● Blocks
 Foraminal
 Epidural
 Facet
TREATMENT
Surgical

● Anterior approach
 Anterior Lumbar Interbody Fusion (ALIF)
 Disc prosthesis
● Posterior approach
 Most surgical treatment for lumbar ASD
● Lateral approach
 Minimally-invasive lateral lumbar interbody fusion (XLIF)
Post-operative anterior and
 The approach is trans-psoas lateral X-rays of lumbosacral
spine
● Combined approach
 THORACIC ADJACENT SEGMENT DISEASE
ASD presenting in the thoracic spine has been underestimated

● Proximal junctional kyphosis is caused by wedging of

the vertebral body
● The cause of this complication is not completely clear
● The guidelines for clinical evaluation, complementary
studies and treatment are similar to those described
for the lumbar spine

MRI of thoracic spine, T2-

weighted sequence, sagittal
section
Thank You