Long-term outcomes of revision fusion for lumbar pseudarthrosis

Clinical article

Restricted access

Object

The number of low-back fusion procedures for the treatment of spine disorders has increased steadily over the past 10 years. Lumbar pseudarthrosis is a potential complication of lumbar arthrodesis and can be associated with significant pain and disability. The aim of this study was to assess, using validated patient-reported outcomes measures, the long-term effectiveness of revision arthrodesis in the treatment of symptomatic pseudarthrosis.

Methods

This is a retrospective study of 47 patients who underwent revision lumbar arthrodesis for pseudarthrosis-associated back pain. Baseline 2-year outcomes were assessed using the following: visual analog scale (VAS) for back pain, Oswestry Disability Index (ODI), Zung Self-Rating Depression Scale, time to narcotic independence, time to return to work, EuroQol health-state utility, and physical and mental quality of life (Short Form [SF]–12 Physical and Mental Component Summary scores).

Results

The mean duration of time between prior fusion and development of symptomatic pseudarthrosis was 2.69 years. Bone morphogenetic protein was used in 4 cases (8.5%) of revision arthrodesis. A significant improvement in VAS back pain (7.31 ± 0.81 vs 5.06 ± 2.64, p = 0.001), ODI (29.74 ± 5.35 vs 25.42 ± 6.0, p = 0.001), and physical health SF-12 (23.83 ± 6.89 vs 27.85 ± 8.90, p = 0.001) scores was observed when comparing baseline and 2-year post–revision arthrodesis scores, respectively, with a mean cumulative 2-year gain of 0.35 quality-adjusted life years. The median time to narcotics independence was 12.16 (interquartile range 1.5–24.0) months and the median time to return to work was 4 months (interquartile range 3–5 months). By 2 years after revision surgery, no patients had experienced pseudarthrosis. The SF-12 Mental Component Summary (44.72 ± 7.90 vs 43.46 ± 7.51, p = 0.43) and Zung Self-Rating Depression Scale scores (39.36 ± 7.48 vs 41.39 ± 10.72, p = 0.37) were not significantly improved by 2 years.

Conclusions

The authors' study suggests that revision lumbar arthrodesis for symptomatic pseudarthrosis provides improvement in low-back pain, disability, and quality of life. Revision lumbar arthrodesis should be considered a viable treatment option for patients with pseudarthrosis-related back pain. Mental health symptoms from pseudarthrosis-associated back pain may be more refractory to revision surgery.

Abbreviations used in this paper: IQR = interquartile range; ODI = Oswestry Disability Index; SF-12 = Short Form–12; VAS = visual analog scale.
Article Information

Contributor Notes

Address correspondence to: Matthew J. McGirt, M.D., 4347 Village at Vanderbilt, Nashville, Tennessee 37232-8618. email: matthew.mcgirt@vanderbilt.com.Please include this information when citing this paper: published online June 24, 2011; DOI: 10.3171/2011.4.SPINE10822.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Albert TJPinto MDenis F: Management of symptomatic lumbar pseudarthrosis with anteroposterior fusion. A functional and radiographic outcome study. Spine (Phila Pa 1976) 25:1231302000

    • Search Google Scholar
    • Export Citation
  • 2

    Biondi JGreenberg BJ: Redecompression and fusion in failed back syndrome patients. J Spinal Disord 3:3623691990

  • 3

    Brown CWOrme TJRichardson HD: The rate of pseudarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparison study. Spine (Phila Pa 1976) 11:9429431986

    • Search Google Scholar
    • Export Citation
  • 4

    Cheh GBridwell KHLenke LGBuchowski JMDaubs MDKim Y: Adjacent segment disease following lumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine (Phila Pa 1976) 32:225322572007

    • Search Google Scholar
    • Export Citation
  • 5

    Copay AGGlassman SDSubach BRBerven SSchuler TCCarreon LY: Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study questionnaire Short Form 36, and pain scales. Spine J 8:9689742008

    • Search Google Scholar
    • Export Citation
  • 6

    Deyo RAMirza SKMartin BI: Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976) 31:272427272006

    • Search Google Scholar
    • Export Citation
  • 7

    Djurasovic MGlassman SDHoward JMCopay AGCarreon LY: Health-related quality of life improvements in patients undergoing lumbar spinal fusion as a revision surgery. Spine (Phila Pa 1976) 2692762011

    • Search Google Scholar
    • Export Citation
  • 8

    Fairbank JCCouper JDavies JBO'Brien JP: The Oswestry low back pain disability questionnaire. Physiotherapy 66:2712731980

  • 9

    Fairbank JCPynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:294029522000

  • 10

    Finnegan WJFenlin JMMarvel JPNardini RJRothman RH: Results of surgical intervention in the symptomatic multiply-operated back patient. Analysis of sixty-seven cases followed for three to seven years. J Bone Joint Surg Am 61:107710821979

    • Search Google Scholar
    • Export Citation
  • 11

    Frymoyer JWMatteri REHanley ENKuhlmann DHowe J: Failed lumbar disc surgery requiring second operation. A long-term follow-up study. Spine (Phila Pa 1976) 3:7111978

    • Search Google Scholar
    • Export Citation
  • 12

    Gallagher EJLiebman MBijur PE: Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 38:6336382001

    • Search Google Scholar
    • Export Citation
  • 13

    Gandek BWare JEAaronson NKApolone GBjorner JBBrazier JE: Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol 51:117111781998

    • Search Google Scholar
    • Export Citation
  • 14

    Geisser MERoth RSRobinson ME: Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain 13:1631701997

    • Search Google Scholar
    • Export Citation
  • 15

    Glassman SGornet MFBranch CPolly D JrPeloza JSchwender JD: MOS short form 36 and Oswestry Disability Index outcomes in lumbar fusion: a multicenter experience. Spine J 6:21262006

    • Search Google Scholar
    • Export Citation
  • 16

    Grönblad MHupli MWennerstrand PJärvinen ELukinmaa AKouri JP: Intercorrelation and test-retest reliability of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) and their correlation with pain intensity in low back pain patients. Clin J Pain 9:1891951993

    • Search Google Scholar
    • Export Citation
  • 17

    Hägg OFritzell PNordwall A: The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J 12:12202003

    • Search Google Scholar
    • Export Citation
  • 18

    Hazard RG: Failed back surgery syndrome: surgical and nonsurgical approaches. Clin Orthop Relat Res 443:2282322006

  • 19

    Herkowitz HNKurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73:8028081991

    • Search Google Scholar
    • Export Citation
  • 20

    Jansson KANémeth GGranath FJönsson BBlomqvist P: Health-related quality of life (EQ-5D) before and one year after surgery for lumbar spinal stenosis. J Bone Joint Surg Br 91:2102162009

    • Search Google Scholar
    • Export Citation
  • 21

    Johnson JACoons SJErgo ASzava-Kovats G: Valuation of EuroQOL (EQ-5D) health states in an adult US sample. Pharmacoeconomics 13:4214331998

    • Search Google Scholar
    • Export Citation
  • 22

    Kim SSMichelsen CB: Revision surgery for failed back surgery syndrome. Spine (Phila Pa 1976) 17:9579601992

  • 23

    Kim YJBridwell KHLenke LGRinella ASEdwards C II: Pseudarthrosis in primary fusions for adult idiopathic scoliosis: incidence, risk factors, and outcome analysis. Spine (Phila Pa 1976) 30:4684742005

    • Search Google Scholar
    • Export Citation
  • 24

    Lauerman WCBradford DSOgilvie JWTransfeldt EE: Results of lumbar pseudarthrosis repair. J Spinal Disord 5:1491571992

  • 25

    Martin GJ JrBoden SDTitus LScarborough NL: New formulations of demineralized bone matrix as a more effective graft alternative in experimental posterolateral lumbar spine arthrodesis. Spine (Phila Pa 1976) 24:6376451999

    • Search Google Scholar
    • Export Citation
  • 26

    Pai SSundaram LJ: Low back pain: an economic assessment in the United States. Orthop Clin North Am 35:152004

  • 27

    Park PGarton HJGala VCHoff JTMcGillicuddy JE: Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976) 29:193819442004

    • Search Google Scholar
    • Export Citation
  • 28

    Pateder DBPark YSKebaish KMCascio BMBuchowski JMSong EW: Spinal fusion after revision surgery for pseudarthrosis in adult scoliosis. Spine (Phila Pa 1976) 31:E314E3192006

    • Search Google Scholar
    • Export Citation
  • 29

    Phillips FMCarlson GDBohlman HHHughes SS: Results of surgery for spinal stenosis adjacent to previous lumbar fusion. J Spinal Disord 13:4324372000

    • Search Google Scholar
    • Export Citation
  • 30

    Ragab ADeshazo RD: Management of back pain in patients with previous back surgery. Am J Med 121:2722782008

  • 31

    Roland MFairbank J: The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine (Phila Pa 1976) 25:311531242000

    • Search Google Scholar
    • Export Citation
  • 32

    Santos ERGoss DGMorcom RKFraser RD: Radiologic assessment of interbody fusion using carbon fiber cages. Spine (Phila Pa 1976) 28:99710012003

    • Search Google Scholar
    • Export Citation
  • 33

    Thurber SSnow MHonts CR: The Zung Self-Rating Depression Scale: convergent validity and diagnostic discrimination. Assessment 9:4014052002

    • Search Google Scholar
    • Export Citation
  • 34

    Tosteson ANLurie JDTosteson TDSkinner JSHerkowitz HAlbert T: Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 149:8458532008

    • Search Google Scholar
    • Export Citation
  • 35

    Ware J JrKosinski MKeller SD: A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:2202331996

    • Search Google Scholar
    • Export Citation
  • 36

    Weinstein JNTosteson TDLurie JDTosteson ANBlood EHanscom B: Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358:7948102008

    • Search Google Scholar
    • Export Citation
  • 37

    Whitecloud TS IIIDavis JMOlive PM: Operative treatment of the degenerated segment adjacent to a lumbar fusion. Spine (Phila Pa 1976) 19:5315361994

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 275 275 68
Full Text Views 112 81 2
PDF Downloads 145 73 2
EPUB Downloads 0 0 0
PubMed
Google Scholar