Cheng David, Hall Michael, Penalosa Bryan, Danisa Olumide, Cheng Wayne
University of Southern California, California, Los Angeles, California.
University of Riverside, Riverside, California.
Int J Spine Surg. 2020 Jun 30;14(3):321-326. doi: 10.14444/7043. eCollection 2020 Jun.
Debate on whether to stop fusion at L5 or to extend fusion to S1 in a long spinal construct has been a controversial topic in spine surgery. Fewer data are available to support whether to include a prior solid fusion at L4-L5 or to extend to S1 during a proximal extension of fusion to T10. The purpose of this review is to report and discuss 2 cases of L5 vertebra fracture after proximal extension of solid L4-L5 fusion to T10 and to provide a guideline to surgeons based on the available literature.
Case report and literature review.
Literature review identified multiple publications with levels of evidence from level 2 to level 4. Advanced L5-S1 degeneration with long-segment fusion to L5 is reported to be greater than 60% with a new rate of symptom development approaching 20%-25%. There is no prior literature specific to L5 fracture development after thoracic lumbar fusion with the lowest instrumented level at a fused L4-L5 segment. Reoperation rate is not consistently affected by the lowest instrumented vertebral level L5 versus sacrum/ilium.
Literature review is inconclusive as to the need to include the lumbosacral junction when performing a proximal extension of fusion from L5 to the thoracic spine, especially during a revision adult deformity surgery. Stress of the long lever arm of a long-segment thoracolumbar fusion above a prior solid L4-L5 fusion could cause the L5 vertebra to split in the coronal plane, resulting in vertebral body fracture even with a mildly degenerated disc at L5-S1 prior to surgery.
在长节段脊柱固定中，关于融合止于L5还是延伸至S1一直是脊柱外科领域颇具争议的话题。关于在将融合近端延伸至T10时，是否应包含L4 - L5节段先前的坚固融合或延伸至S1，可供支持的数据较少。本综述的目的是报告并讨论2例在将坚固的L4 - L5融合近端延伸至T10后发生L5椎体骨折的病例，并根据现有文献为外科医生提供指导。
病例报告及文献综述。
文献综述发现了多篇证据等级从2级到4级的出版物。据报道，L5 - S1节段进展性退变且长节段融合至L5的发生率超过60%，新的症状出现率接近20% - 25%。此前尚无关于在L4 - L5节段融合作为最低固定节段的胸腰段融合术后发生L5骨折的具体文献。再次手术率并未始终受到最低固定椎体节段是L5还是骶骨/髂骨的影响。
关于在从L5向胸椎进行融合近端延伸时，尤其是在成人脊柱畸形翻修手术中，是否需要包含腰骶关节，文献综述尚无定论。在先前坚固的L4 - L5融合上方进行长节段胸腰段融合时，长杠杆臂产生的应力可能导致L5椎体在冠状面劈裂，即使术前L5 - S1椎间盘仅有轻度退变，也会导致椎体骨折。
4级。
