Re-operation after Long-Segment Fusions for Adult Spinal Deformity: The Impact of Extending the Construct below the Lumbar Spine

Christopher D. Witiw, Richard G. Fessler, Stacie Nguyen, Praveen Mummaneni, Neel Anand, Donald Blaskiewicz, Juan Uribe, Michael Y. Wang, Adam S. Kanter, David Okonkwo, Paul Park, Vedat Deviren, Behrooz A. Akbarnia, Robert K. Eastlack, Christopher Shaffrey, Gregory M. Mundis

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Deciding where to end a long-segment fusion for adult spinal deformity (ASD) may be a challenge, particularly in the absence of an abnormality at L5/S1. Some suggest prophylactic extension of the construct to the sacrum and/or ilium (S/I) to protect against distal junctional failure, while others support terminating in the lower lumbar spine to preserve motion. OBJECTIVE: To compare the risk of re-operation after long-segment fusions for ASD that ends at L4 or L5 (L4/5) vs S/I. METHODS: A multicenter database of patients treated for ASD by circumferential minimally invasive surgery or hybrid surgical technique was screened for individuals with long fusions (≥4 vertebral levels) ending at L4 or below and with at least 2 yr of follow-up. Multivariate regression modeling was used to compare surgical morbidity between the L4/5 and S/I groups, and Cox proportional hazard modeling was used to compare risk of re-operation. RESULTS: There were 45 subjects with fusion to L4/5 and 71 to S/I. Over a 32-mo median follow-up, 41 re-operations were performed; 6 were for distal junctional failure. In those with normal or mild degeneration at L5/S1, fusion to S/I afforded no significant change in re-operative risk (hazard ratio = 1.18 [95% confidence interval: 0.53-2.62], P = .682). In those undergoing circumferential minimally invasive surgery correction, fusion to S/I was associated with significantly greater blood loss (499.6 cc, P < .001) and surgical time (97.5 min, P = .04). CONCLUSION: In the setting of a normal ormildly degenerated L5/S1 disc space, fusion to the sacrum/ilium did not significantly change the risk of requiring a re-operation after a long-segment fusion for ASD.

Original languageEnglish (US)
Pages (from-to)211-218
Number of pages8
JournalClinical neurosurgery
Issue number2
StatePublished - Feb 1 2018


  • Adjacent segment degeneration
  • Adult spinal deformity
  • Distal junctional failure
  • Reoperation
  • Spine

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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