Thoracolumbar deformity arthrodesis stopping at L5 - Fate of the L5-S1 disc, minimum 5-year follow-up

Study Design. A retrospective long-term follow-up study. Objective. Evaluate the fate of L5-S1 disc analyzing subsequent disc degeneration and associated risk factors for degeneration at minimum 5-year follow-up ( average 9-year follow-up). Summary of Background Data. Two previous studies reported the results of long deformity fusions terminating at L5 with minimum 2-year follow-up only. Methods. Thirty-one consecutive patients with an average age of 45 years ( range, 20-62 years) were fused from the thoracic spine to L5 and were evaluated at a mean follow-up of 9.4 years ( range, 5-20.1 year). Patients were evaluated before surgery, after surgery, and latest follow-up with radiographs and Scoliosis Research Society Patient Questionnaire-24 scores. Disc degeneration using validated radiographic Weiner grades. Grade 0 to 1 discs were "healthy" and Grade 2 to 3 were degenerated. Patients with "healthy" discs preoperative that subsequently degenerated were designated subsequent advanced degeneration ( SAD). Results. Two out of 31 patients had preoperative advanced degeneration of the L5-S1 disc ( Weiner grade 2-3). Three additional patients had an early revision to the sacrum secondary to sagittal imbalance not thought to be related to SAD. Twenty-six out of 31 patients were assessed as "healthy discs" preoperative ( Weiner grade 0-1) and were evaluated for SAD. By latest follow-up, L5-S1 SAD developed in 18 of these 26 patients (69%). Risk factors for the development of SAD included long fusions extending into the upper thoracic spine down to L5 ( P = 0.02) and having a circumferential lumbar fusion ( P = 0.02). Although preoperative sagittal balance was not significantly different between the "healthy" and SAD group, sagittal balance at follow-up was: C7 plumb > 5 cm in 67% of SAD patients and only 13% of "healthy" disc patients ( P = 0.009). There was a trend toward inferior Scoliosis Research Society Patient Questionnaire-24 pain scores at follow-up in SAD patients ( average score 4.1 vs. 3.4, P = 0.13). Eleven out of 30 patients (35%) had subsequent spinal surgery with 7 of 31 (23%) having extension of their fusion to the sacrum. An additional 6 of 31 (19%) were considered for extension to the sacrum but comorbidities precluded surgery ( 3 patients) or the patients declined further surgery ( 3 patients). Conclusion. Advanced L5-S1 DDD developed in 69% of deformity patients after long fusions to L5 with 5 to 15 year follow-up. SAD frequently results in significant positive sagittal balance at a minimum 5-year follow-up. Long fusions to the upper thoracic spine down to L5 and circumferential fusion may further promote subsequent L5-S1 disc degeneration.