Skip to main content
SpringerLink
Log in

Selecting caudal fusion levels: 2 year functional and stiffness outcomes with matched pairs analysis in multilevel fusion to L5 versus S1

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

Controversy persists as to whether to end multilevel thoracolumbar fusions caudally at L5 or S1. Some argue that stopping at L5 may preserve greater function, but there are few data comparing functional limitations due to lumbar stiffness in patients with fusion to L5 versus S1. The aim of this study was to evaluate whether patients undergoing multilevel thoracolumbar fusions with an L5 caudal endpoint have a better lumbosacral function than patients with an S1 caudal endpoint.

Methods

Patients undergoing successful thoracolumbar fusion of 5 or more levels to L5 or S1, with solid fusion at 2 year follow-up, were examined from a single European center in addition to a multi-center North American database of 237 patients. In total, 40 patients with a distal stopping point of L5 were matched with a subset of 40 patients with a distal endpoint of S1 ± pelvic fixation. The L5 and S1 groups were matched for the final Oswestry Disability Index (ODI), Sagittal Vertical Axis (SVA C7-S1), number of fusion levels, and age. Impacts of lumbar stiffness on function as measured by the Lumbar Stiffness Disability Index (LSDI) were compared using the conditional logistic regression.

Results

After matching, there was no significant difference between the S1 and L5 groups for the final ODI (29.22 ± 21.6 for S1 versus 29.21 ± 21.7 for L5; p = 0.98), SVA (29.5 ± 40.3 mm for S1 versus 33.7 ± 37.1 mm for L5; p = 0.97), mean age (61.6 ± 11.0 years for S1 versus 58.3 ± 12.6 years for L5; p = 0.23), and number of fusion levels (9.7 ± 3.3 levels for S1 versus 9.0 ± 3 levels for L5; p = 0.34). The final 2-year postoperative LSDI scores were not significantly different between the S1 group (28.08 ± 21.47) and L5 group (29.21 ± 21.66) (hazard ratio 0.99, 95 % CI 0.97–1.03, p = 0.81).

Conclusion

The analysis of patients with multilevel thoracolumbar fusions demonstrated that after minimum 2 year follow-up, self-reported functional impacts of lumbar stiffness were not significantly different between the patients with distal endpoints of L5 versus S1. The choice of distal fusion level of L5 does not appear to retain sufficient spinal flexibility to substantially affect postoperative function.

Level of evidence

Level III.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Bridwell KH (2004) Selection of instrumentation and fusion levels for scoliosis: where to start and where to stop. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 1:1–8. doi:10.3171/spi.2004.1.1.0001

    Article  PubMed  Google Scholar 

  2. Swamy G, Berven SH, Bradford DS (2007) The selection of L5 versus S1 in long fusions for adult idiopathic scoliosis. Neurosurg Clin N Am 18:281–288. doi:10.1016/j.nec.2007.01.010

    Article  PubMed  Google Scholar 

  3. Bridwell KH, Edwards CC 2nd, Lenke LG (2003) The pros and cons to saving the L5–S1 motion segment in a long scoliosis fusion construct. Spine 28:S234–S242. doi:10.1097/01.BRS.0000092462.45111.27

    Article  PubMed  Google Scholar 

  4. Brown KM, Ludwig SC, Gelb DE (2004) Radiographic predictors of outcome after long fusion to L5 in adult scoliosis. J Spinal Disord Techn 17:358–366

    Article  Google Scholar 

  5. Kwon BK, Elgafy H, Keynan O, Fisher CG, Boyd MC, Paquette SJ, Dvorak MF (2006) Progressive junctional kyphosis at the caudal end of lumbar instrumented fusion: etiology, predictors, and treatment. Spine 31:1943–1951. doi:10.1097/01.brs.0000229258.83071.db

    Article  PubMed  Google Scholar 

  6. Edwards CC 2nd, Bridwell KH, Patel A, Rinella AS, Berra A, Lenke LG (2004) Long adult deformity fusions to L5 and the sacrum. A matched cohort analysis. Spine 29:1996–2005

    Article  PubMed  Google Scholar 

  7. Engsberg JR, Bridwell KH, Wagner JM, Uhrich ML, Blanke K, Lenke LG (2003) Gait changes as the result of deformity reconstruction surgery in a group of adults with lumbar scoliosis. Spine 28:1836–1843 (discussion 1844)

  8. Bafus T, Shea M, Hart R (2005) Impairment of perineal care functions after long fusions of the lumbar spine. Clin Orthop Related Res 111–114

  9. Daniels AH, Smith JS, Hiratzka J, Ames CP, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Klineberg EO, Burton D, Mundis GM, Line B, Hart RA, International Spine Study G (2015) Functional limitations due to lumbar stiffness in adults with and without spinal deformity. Spine 40:1599–1604. doi:10.1097/BRS.0000000000001090

    Article  PubMed  Google Scholar 

  10. Hart RA, Gundle KR, Pro SL, Marshall LM (2013) Lumbar Stiffness Disability Index: pilot testing of consistency, reliability, and validity. Spine J Off J North Am Spine Soc 13:157–161. doi:10.1016/j.spinee.2012.12.001

    Article  Google Scholar 

  11. Hart RA AP, Mirza S (2012) What is a Complication? Toward Objective Definition and Reporting of Adverse Outcomes. In: Benzel (ed) The cervical spine. Lippincott, Williams, and Wilkins, Philadelphia pp. 1217–1222

  12. Hart RA HJ, Kane M, et al (2016) Stiffness after Pan-Lumbar Arthrodesis for Adult Spinal Deformity Does Not Significantly Impact Patient Functional Status or Satisfaction. Spine (in press)

  13. Kuhns CA, Bridwell KH, Lenke LG, Amor C, Lehman RA, Buchowski JM, Edwards C 2nd, Christine B (2007) Thoracolumbar deformity arthrodesis stopping at L5: fate of the L5–S1 disc, minimum 5-year follow-up. Spine 32:2771–2776. doi:10.1097/BRS.0b013e31815a7ece

    Article  PubMed  Google Scholar 

  14. Polly DW Jr, Hamill CL, Bridwell KH (2006) Debate: to fuse or not to fuse to the sacrum, the fate of the L5–S1 disc. Spine 31:S179–S184. doi:10.1097/01.brs.0000234761.87368.ee

    Article  PubMed  Google Scholar 

  15. Smith JS, Shaffrey CI, Glassman SD, Berven SH, Schwab FJ, Hamill CL, Horton WC, Ondra SL, Sansur CA, Bridwell KH, Spinal Deformity Study G (2011) Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age. Spine 36:817–824. doi:10.1097/BRS.0b013e3181e21783

    Article  PubMed  Google Scholar 

  16. Koller H, Pfanz C, Meier O, Hitzl W, Mayer M, Bullmann V, Schulte TL (2015) Factors influencing radiographic and clinical outcomes in adult scoliosis surgery: a study of 448 European patients. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Sect Cerv Spine Res Soc. doi:10.1007/s00586-015-3898-x

    Google Scholar 

  17. Sciubba DM, Scheer JK, Smith JS, Lafage V, Klineberg E, Gupta M, Mundis GM, Protopsaltis TS, Kim HJ, Hiratzka JR, Koski T, Shaffrey CI, Bess S, Hart RA, Ames CP, International Spine Study G (2015) Which daily functions are most affected by stiffness following total lumbar fusion: comparison of upper thoracic and thoracolumbar proximal endpoints. Spine 40:1338–1344. doi:10.1097/BRS.0000000000000968

    Article  PubMed  Google Scholar 

  18. Deisseroth K, Hart RA (2012) Symptoms of post-traumatic stress following elective lumbar spinal arthrodesis. Spine 37:1628–1633. doi:10.1097/BRS.0b013e318255e214

    Article  PubMed  Google Scholar 

  19. Hart R, Perry E, Hiratzka S, Kane M, Deisseroth K (2013) Post-traumatic stress symptoms after elective lumbar arthrodesis are associated with reduced clinical benefit. Spine 38:1508–1515. doi:10.1097/BRS.0b013e318285f05a

    Article  PubMed  Google Scholar 

  20. Mannion AF, Junge A, Fairbank JC, Dvorak J, Grob D (2006) Development of a German version of the Oswestry Disability Index. Part 1: cross-cultural adaptation, reliability, and validity. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Sect Cerv Spine Res Soc 15:55–65. doi:10.1007/s00586-004-0815-0

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopedics, Adult Spinal Deformity Service, Brown University, 100 Butler Drive, Providence, RI, 02906, USA

    Alan H. Daniels & Adam E. M. Eltorai

  2. Spine-Center, Werner-Wicker-Clinic, Bad Wildungen, Germany

    Heiko Koller, Michael Mayer & Oliver Meier

  3. Orthopaedics, Spinal Deformity Service, Swedish Health System, Seattle, WA, USA

    Shannon L. Hiratzka, Alec Gabriel Contag, Jayme Hiratzka & Robert A. Hart

  4. Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, USA

    D. Kojo Hamilton

  5. Neurosurgery, University of Virginia Health System, Charlottesville, USA

    Christopher I. Shaffrey & Justin S. Smith

  6. Orthopaedics, Denver International Spine Clinic. Presbyterian/St. Luke’s Rocky Mountain Hospital for Children, Denver, CO, USA

    Shay Bess

  7. Orthopaedics, University of California, Davis, USA

    Eric O. Klineberg

  8. Neurosurgery, University of California San Francisco, San Francisco, USA

    Christopher P. Ames

  9. Orthopaedics, Hospital for Special Surgery, New York, USA

    Virginie Lafage & Frank J. Schwab

  10. ISSGF, Littleton, USA

    Breton Line & International Spine Study Group

Authors
  1. Alan H. Daniels
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Heiko Koller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shannon L. Hiratzka
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michael Mayer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Oliver Meier
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Alec Gabriel Contag
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Adam E. M. Eltorai
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jayme Hiratzka
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. D. Kojo Hamilton
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Christopher I. Shaffrey
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Justin S. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Shay Bess
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Eric O. Klineberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Christopher P. Ames
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Virginie Lafage
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Breton Line
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Frank J. Schwab
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Robert A. Hart
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. International Spine Study Group
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alan H. Daniels.

Ethics declarations

Conflict of interest

None of the authors have any conflict of interest in connection with this study.

Funding

Funding for the ISSG and this work was supported by a grant from Depuy-Synthes.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Daniels, A.H., Koller, H., Hiratzka, S.L. et al. Selecting caudal fusion levels: 2 year functional and stiffness outcomes with matched pairs analysis in multilevel fusion to L5 versus S1. Eur Spine J 26, 1645–1651 (2017). https://doi.org/10.1007/s00586-016-4790-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-016-4790-z

Keywords

Search

Navigation