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Adjacent Segment Pathology: Progressive Disease Course or a Product of Iatrogenic Fusion?

  • Andrew Jack (a1), Godefroy Hardy St-Pierre (a1) and Andrew Nataraj (a1)

Abstract

Objective: Cervical spine clinical adjacent segment pathology (CASP) has a reported 3% annual incidence and 26% ten-year prevalence. Its pathophysiology remains controversial, whether due to mechanical stress of a fusion segment on adjacent levels or due to patient propensity to develop progressive degenerative change. We investigate this relationship by comparing prevalence of CASP in traumatic and spondylotic patient cohorts. Method: A retrospective review of traumatic cervical spine fusion cases performed by the local group of neurosurgeons from 2004-2008 was completed. Surgery for CASP and presence of radiological adjacent segment pathology (RASP) were identified by telephone and electronic medical record (EMR) review, and compared to those in patients having elective cervical fusion for degenerative disease. Results: There was a higher proportion of males (50/100 vs. 37/46, p<0.001) in the traumatic group. Median age between groups was not significantly different (47 years in the trauma cohort, 50 years in the degenerative cohort; p>0.05). Mean follow-up times were different (6.4 years in the trauma group, 7.1 years in the degenerative group; p<0.01), although this was not thought to be clinically significant. The degenerative group was found to have a significantly higher reoperation rate for CASP (10/100 vs. 0/46, p=0.031, Fisher’s Exact Test), and rate of RASP (20/100 vs. 1/32, p=0.025) Conclusion: This is the only cohort study to our knowledge comparing surgery for CASP in trauma patients to those with degenerative disease. A higher rate of repeat surgery in degenerative disease patients was found. This suggests that CASP is more related to patient factors predisposing to progressive degenerative disease and not increased mechanical stress.

Pathologie du segment adjacent : progression de la maladie ou conséquence de la fusion iatrogénique? Objectif: Selon la littérature, l’incidence annuelle d’une pathologie clinique du segment adjacent de la colonne cervicale (PSACC) est de 3% et sa prévalence à 10 ans de 26%. Sa physiopathologie demeure controversée : est-ce dû au stress mécanique du segment de fusion sur les niveaux adjacents ou à la susceptibilité du patient à un processus dégénératif ? Nous avons étudié cette relation en comparant la prévalence d’une PSACC dans une cohorte de patients dont la pathologie initiale était un traumatisme et une cohorte de patients dont la pathologie initiale était une spondylose. Méthodologie: Nous avons procédé à une étude rétrospective des dossiers des patients traités par le groupe local de neurochirurgiens de 2004 à 2008 pour fusion de la colonne cervicale suite à un traumatisme. Nous avons identifié par téléphone, ainsi que par une revue des dossiers médicaux électroniques, les patients qui avaient subi une chirurgie pour une PSACC et la présence d’une pathologie du segment adjacent confirmé par radiologie (PSAR) chez ces patients. Nous avons comparé ces patients à ceux qui subissaient une fusion cervicale élective pour une maladie dégénérative. Résultats: Nous avons constaté qu’il y avait une proportion plus élevée d’hommes (50/100 par rapport à 37/46 ; p ) dans le groupe de patients qui présentaient une pathologie d’origine traumatique. L’âge médian n’était pas significativement différent entre les groupes (47 ans dans la cohorte traumatique et 50 ans dans la cohorte spondylotique ; p > 0,05). La durée du suivi était différente entre les groupes (6,4 ans dans le groupe traumatique et 7,1 ans dans le groupe dégénératif ; p <0,01), ce qui n’a pas été considéré comme étant significatif au point de vue clinique. Le taux de réintervention pour une PSACC ainsi que le taux de PSAR étaient significativement plus élevés dans le groupe de patients présentant une pathologie d’origine dégénérative (10/100 par rapport à 0/46 ; p = 0,031 par la méthode exacte de Fisher) et (20/100 par rapport à 1/32 ; p = 0,025) respectivement. Conclusion: À notre connaissance, ceci constitue la seule étude de cohorte comparant la chirurgie pour une PSACC chez des patients dont la pathologie est d’origine traumatique et chez des patients présentant une maladie dégénérative. Nous avons constaté que le taux de réintervention était plus élevé chez les patients dont la pathologie était d’origine dégénérative, ce qui est en faveur de la présence de facteurs prédisposant à une maladie dégénérative progressive et non à un accroissement du stress mécanique chez les patients présentant une PSACC.

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Copyright

Corresponding author

Correspondence to: Andrew Jack, 2D1. 02 Mackenzie Centre, Division of Neurosurgery, Department of Surgery, University of Alberta Hospital T6G 2B7. Email: asjack@ualberta.ca

References

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Adjacent Segment Pathology: Progressive Disease Course or a Product of Iatrogenic Fusion?

  • Andrew Jack (a1), Godefroy Hardy St-Pierre (a1) and Andrew Nataraj (a1)

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