Revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, adjacent-segment disease, or same-level recurrent stenosis. Part 1. Two-year outcomes and clinical efficacy

Clinical article

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Same-level recurrent lumbar stenosis, pseudarthrosis, and adjacent-segment disease (ASD) are potential complications that can occur after index lumbar spine surgery, leading to significant discomfort and radicular pain. While numerous studies have demonstrated excellent results following index lumbar spine surgery in elderly patients (age > 65 years), the effectiveness of revision lumbar surgery in this cohort remains unclear. The aim of this study was to assess the long-term effectiveness of revision lumbar decompression and fusion in the treatment of symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis, using validated patient-reported outcomes.


After a review of the institutional database, 69 patients who had undergone revision neural decompression and instrumented fusion for ASD (28 patients), pseudarthrosis (17 patients), or same-level recurrent stenosis (24 patients) were included in this study. Baseline and 2-year scores on the visual analog scale for leg pain (VAS-LP), VAS for back pain (VAS-BP), Oswestry Disability Index (ODI), and Zung Self-Rating Depression Scale (SDS) as well as the time to narcotic independence, time to return to baseline activity level, health state utility (EQ-5D, the EuroQol-5D health survey), and physical and mental component summary scores of the 12-Item Short-Form Health Survey (SF-12 PCS and MCS) were assessed.


Compared with the preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (mean ± standard deviation 9 ± 2 vs 4.01 ± 2.56, p = 0.001), pseudarthrosis (7.41 ± 1 vs 5.52 ± 3.08, p = 0.02), and same-level recurrent stenosis (7 ± 2.00 vs 5.00 ± 2.34, p = 0.003). The 2-year ODI was also significantly improved after surgery for ASD (29 ± 9 vs 23.10 ± 10.18, p = 0.001), pseudarthrosis (28.47 ± 5.85 vs 24.41 ± 7.75, p = 0.001), and same-level recurrent stenosis (30.83 ± 5.28 vs 26.29 ± 4.10, p = 0.003). The Zung SDS score and SF-12 MCS did not change appreciably after surgery in any of the cohorts, with an overall mean 2-year change of 1.01 ± 5.32 (p = 0.46) and 2.02 ± 9.25 (p = 0.22), respectively.


Data in this study suggest that revision lumbar decompression and extension of fusion for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis provides improvement in low-back pain, disability, and quality of life and should be considered a viable treatment option for elderly patients with persistent or recurrent back and radicular pain. Mental health symptoms may be more refractory to revision surgery.

Article Information

Address correspondence to: Owoicho Adogwa, M.D., M.P.H., 215 Light Hall, Nashville, Tennessee 37232. email:

Please include this information when citing this paper: published online December 14, 2012; DOI: 10.3171/2012.11.SPINE12224.

© AANS, except where prohibited by US copyright law.



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    Kaplan-Meier plots depicting the duration of postoperative narcotic use for patients undergoing revision decompression and fusion for symptomatic lumbar pseudarthrosis, ASD, or same-level recurrent stenosis. The median time (IQR) to narcotic independence following surgery for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis was 4 (1.5–24.33), 3 (1–24.33), and 12.16 (1.5–24.33) months, respectively.

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    Kaplan-Meier plots depicting the duration of postoperative time to return to baseline activity level for patients undergoing revision decompression and arthrodesis for symptomatic lumbar pseudarthrosis, ASD, or same-level recurrent stenosis. The median time (IQR) to return to the baseline activity level following surgery for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis was 5 (3–6), 4.5 (3–8), and 4 (3–5) months, respectively.

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    Bar graph depicting cumulative 2-year gain in health utility after revision decompression and fusion for symptomatic ASD, pseudarthrosis, and same-level recurrent stenosis. Overall, the 2-year cumulative health utility gained after revision decompression and fusion was 0.35 QALY (ASD: 0.34 QALY, pseudarthrosis: 0.31 QALY, and samelevel recurrent stenosis: 0.40 QALY). Left bars indicate the preoperative global health status; right bars, the postoperative global health status.



Aalto TJMalmivaara AKovacs FHerno AAlen MSalmi L: Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976) 31:E648E6632006


Adogwa OParker SLShau DMendelhall SKCheng JAaronson O: Long-term outcomes of revision fusion for lumbar pseudarthrosis. Clinical article. J Neurosurg Spine 15:3933982011


Adogwa OParker SLShau DNMendenhall SKDevin CJCheng JS: Cost per quality-adjusted life year gained of laminectomy and extension of instrumented fusion for adjacent-segment disease: defining the value of surgical intervention. Clinical article. J Neurosurg Spine 16:1411462012


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


Aota YKumano KHirabayashi S: Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord 8:464 4731995


Arinzon ZHFredman BZohar EShabat SFeldman JSJedeikin R: Surgical management of spinal stenosis: a comparison of immediate and long term outcome in two geriatric patient populations. Arch Gerontol Geriatr 36:273 2792003


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


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


Carreon LYPuno RMDimar JR IIGlassman SDJohnson JR: Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85-A:208920922003


Cassinelli EHEubanks JVogt MFurey CYoo JBohlman HH: Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine (Phila Pa 1976) 32:2302352007


Cheh GBridwell KHLenke LGBuchowski JMDaubs MDKim Y: Adjacent segment disease followinglumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine (Phila Pa 1976) 32:2253 22572007


Conrad DADeyo RA: Economic decision analysis in the diagnosis and treatment of low back pain. A methodologic primer. Spine (Phila Pa 1976) 19:18 Suppl2101S2106S1994


Dagenais SCaro JHaldeman S: A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 8:8202008


den Boer JJOostendorp RABeems TMunneke MEvers AW: Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors. Pain 123:45522006


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


Doxey NCDzioba RBMitson GLLacroix JM: Predictors of outcome in back surgery candidates. J Clin Psychol 44:611 6221988


Ebeling UKalbarcyk HReulen HJ: Microsurgical reoperation following lumbar disc surgery. Timing, surgical findings, and outcome in 92 patient. J Neurosurg 70:3974041989


Etebar SCahill DW: Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg 90:2 Suppl1631691999


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


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


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


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


Goupille P: Causes of failed back surgery syndrome. Rev Rhum Engl Ed 63:2352391996


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


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


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


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


Kilinçer CSteinmetz MPSohn MJBenzel ECBingaman W: Effects of age on the perioperative characteristics and short-term outcome of posterior lumbar fusion surgery. J Neurosurg Spine 3:34392005


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


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


Kumar MNBaklanov AChopin D: Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 10:3143192001


Kumar MNJacquot FHall H: Long-term follow-up of functional outcomes and radiographic changes at adjacent levels following lumbar spine fusion for degenerative disc disease. Eur Spine J 10:3093132001


Lauerman WCBradford DSOgilvie JWTransfeldt EE: Results of lumbar pseudarthrosis repair. J Spinal Disord 5:149 1571992


Lee CK: Accelerated degeneration of the segment adjacent to a lumbar fusion. Spine (Phila Pa 1976) 13:3753771988


McAlinden NMOei TP: Validation of the Quality of Life Inventory for patients with anxiety and depression. Compr Psychiatry 47:3073142006


Ozgen SNaderi SOzek MMPamir MN: Findings and outcome of revision lumbar disc surgery. J Spinal Disord 12:2872921999


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


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


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


Raffo CSLauerman WC: Predicting morbidity and mortality of lumbar spine arthrodesis in patients in their ninth decade. Spine (Phila Pa 1976) 31:991032006


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


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


Schlegel JDSmith JASchleusener RL: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Spine (Phila Pa 1976) 21:9709811996


Spengler DM: Lumbar discectomy. Results with limited disc excision and selective foraminotomy. Spine (Phila Pa 1976) 7:6046071982


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


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


Trief PMPloutz-Snyder RFredrickson BE: Emotional health predicts pain and function after fusion: a prospective multicenter study. Spine (Phila Pa 1976) 31:8238302006


Vitaz TWRaque GHShields CBGlassman SD: Surgical treatment of lumbar spinal stenosis in patients older than 75 years of age. J Neurosurg 91:2 Suppl1811851999


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


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


Yone KSakou TKawauchi YYamaguchi MYanase M: Indication of fusion for lumbar spinal stenosis in elderly patients and its significance. Spine (Phila Pa 1976) 21:2422481996


Zung WWRichards CBShort MJ: Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 13:5085151965


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