Jokeit Moritz, Tsagkaris Christos, Altorfer Franziska C S, Cornaz Frédéric, Snedeker Jess G, Farshad Mazda, Widmer Jonas
Spine Biomechanics, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Lengghalde 5, CH-8008, Zurich, Switzerland.
Institute for Biomechanics, ETH Zurich, Zurich, Switzerland.
J Orthop Surg Res. 2025 Apr 29;20(1):425. doi: 10.1186/s13018-025-05561-1.
Adjacent segment degeneration (ASDeg) and disease (ASDis) remain significant challenges following lumbar spinal fusion surgery, with reported incidences of 36% for ASDeg and 11% for ASDis within two to seven years post-operation. However, the mechanisms leading to the development of ASDeg are still poorly understood. This comprehensive review aims to elucidate the multifactorial etiology of ASDeg by examining important iatrogenic alterations associated with spinal fusion.
A systematic review following PRISMA guidelines was conducted to identify clinical studies quantifying the occurrence of ASDeg and ASDis after lumbar fusion surgery. An EMBASE and citation search up to April 2023 yielded 378 articles. Data extracted encompassed study design, fusion type, sample size, patient age, and incidence of ASDeg and ASDis. A total of 87 publications were analyzed in the context of iatrogenic alterations caused by surgical access (muscle damage, ligament damage, facet joint damage) and instrumentation (fusion angle, immobilization).
Ligament damage emerged as the most impactful iatrogenic factor promoting ASDeg and ASDis development. Similarly, muscle damage had a significant impact on long-term musculoskeletal health, with muscle-sparing approaches potentially reducing ASDis rates. Immobilization led to compensatory increased motion at adjacent segments; however, the causal link to degeneration remains inconclusive. Fusion angle showed low evidence for a strong impact due to inconsistent findings across studies. Facet joint violations were likely contributing factors but not primary initiators of ASDeg.
Based on the analyzed literature, ligament and muscle damage are the most impactful iatrogenic factors contributing to ASDeg and ASDis development. Minimally invasive techniques, careful retractor placement, and ligament-preserving decompression may help mitigate these effects by reducing undue muscle and ligament trauma. Although it is not possible to definitively advocate for one or more techniques, the principle of selecting the most tissue-sparing approach needs to be scaled across surgical planning and execution. Further research is necessary to fully elucidate these mechanisms and inform surgical practices to mitigate ASDeg risk.
腰椎融合手术后，相邻节段退变（ASDeg）和疾病（ASDis）仍然是重大挑战，据报道，术后两到七年内ASDeg的发生率为36%，ASDis的发生率为11%。然而，导致ASDeg发生发展的机制仍知之甚少。本综述旨在通过研究与脊柱融合相关的重要医源性改变，阐明ASDeg的多因素病因。
按照PRISMA指南进行系统综述，以确定量化腰椎融合术后ASDeg和ASDis发生率的临床研究。截至2023年4月，通过EMBASE和文献检索共获得378篇文章。提取的数据包括研究设计、融合类型、样本量、患者年龄以及ASDeg和ASDis的发生率。在由手术入路（肌肉损伤、韧带损伤、小关节损伤）和内固定（融合角度、固定）引起的医源性改变背景下，共分析了87篇出版物。
韧带损伤是促进ASDeg和ASDis发生发展的最具影响力的医源性因素。同样，肌肉损伤对长期肌肉骨骼健康有显著影响，保留肌肉的方法可能会降低ASDis的发生率。固定导致相邻节段代偿性运动增加；然而，与退变的因果关系仍不确定。由于各研究结果不一致，融合角度对其有强烈影响的证据不足。小关节损伤可能是促成因素，但不是ASDeg的主要引发因素。
基于分析的文献，韧带和肌肉损伤是导致ASDeg和ASDis发生发展的最具影响力的医源性因素。微创技术、小心放置牵开器和保留韧带的减压术可能有助于通过减少不必要的肌肉和韧带创伤来减轻这些影响。虽然不可能明确提倡一种或多种技术，但在手术规划和实施过程中，需要推广选择对组织损伤最小方法的原则。需要进一步研究以充分阐明这些机制，并为减轻ASDeg风险的手术实践提供依据。
