Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine

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Marc Röllinghoff *
Klaus Schlüter-Brust
Daniel Groos
Rolf Sobottke
Joern William-Patrick Michael
Peer Eysel
Karl Stefan Delank
(*) Corresponding Author:
Marc Röllinghoff | marc.roellinghoff@gmx.de

Abstract

In the treatment of multilevel degenerative disorders of the lumbar spine, spondylodesis plays a controversial role. Most patients can be treated conservatively with success. Multilevel lumbar fusion with instrumentation is associated with severe complications like failed back surgery syndrome, implant failure, and adjacent segment disease (ASD). This retrospective study examines the records of 70 elderly patients with degenerative changes or instability of the lumbar spine treated between 2002 and 2007 with spondylodesis of more than two segments. Sixty-four patients were included; 5 patients had died and one patient was lost to follow-up. We evaluated complications, clinical/radiological outcomes, and success of fusion. Flexion-extension and standing X-rays in two planes, MRI, and/or CT scans were obtained pre-operatively. Patients were assessed clinically using the Oswestry disability index (ODI) and a Visual Analogue Scale (VAS). Surgery performed was dorsolateral fusion (46.9%) or dorsal fusion with anterior lumbar interbody fusion (ALIF; 53.1%). Additional decompression was carried out in 37.5% of patients. Mean follow-up was 29.4±5.4 months. Average patient age was 64.7±4.3 years. Clinical outcomes were not satisfactory for all patients. VAS scores improved from 8.6±1.3 to 5.6±3.0 pre- to post-operatively, without statistical significance. ODI was also not significantly improved (56.1±22.3 pre- and 45.1±26.4 post-operatively). Successful fusion, defined as adequate bone mass with trabeculation at the facets and transverse processes or in the intervertebral segments, did not correlate with good clinical outcomes. Thirty-five of 64 patients (54%) showed signs of pedicle screw loosening, especially of the screws at S1. However, only 7 of these 35 (20%) complained of corresponding back pain. Revision surgery was required in 24 of 64 patients (38%). Of these, indications were adjacent segment disease (16 cases), pedicle screw loosening (7 cases), and infection (one case). At follow-up of 29.4 months, patients with radiographic ASD had worse ODI scores than patients without (54.7 vs. 36.6; P less than 0.001). Multilevel fusion for degenerative disease still has a high rate of complications, up to 50%. The problem of adjacent segment disease after fusion surgery has not yet been solved. This study underscores the need for strict indication guidelines to perform lumbar spine fusion of more than two levels.

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Author Biographies

Marc Röllinghoff, Orthopaedic Surgeon, MD

Department of Orthopaedic and Trauma Surgery, University of Cologne

Klaus Schlüter-Brust, Orthopaedic Surgeon, MD

Department of Orthopaedic and Trauma Surgery, University of Cologne

Daniel Groos, medical student

Department of Orthopaedic and Trauma Surgery, University of Cologne

Rolf Sobottke, Department of Orthopaedic Surgery, University of Cologne

Department of Orthopaedic and Trauma Surgery, University of Cologne

Joern William-Patrick Michael, Orthopaedic Surgeon, MD

Department of Orthopaedic and Trauma Surgery, University of Cologne

Peer Eysel, Spine Surgeon, MD, PhD

Department of Orthopaedic and Trauma Surgery, University of Cologne

Karl Stefan Delank, Spine Surgeon, MD,

Department of Orthopaedic and Trauma Surgery, University of Cologne