SpineUniverse Case Study Library

Minimally Invasive Treatment of Adjacent Segment Disease


The patient is a 67-year-old female who presented two years after an open L4-S1 posterior decompression and instrumented fusion at an outside institution. Her chief complaints were progressive mechanical back pain and neurogenic claudication. She had attempted non-operative measures with minimal relief.


There was a well-healed midline lumbar incision. Motor exam was normal in the upper and lower extremities. Reflexes were symmetric and brisk. There was no clonus and negative Babinski sign. Sensation was normal. She had excellent standing posture without obvious sagittal or coronal plane deformity on physical examination. Her back and leg numeric pain score (NPS) was 6.5 out of 10.

Pre-treatment Imaging

MRI of the lumbar spine demonstrated L3-L4 stenosis above the previous construct (Figures 1A and 1B). Dynamic x-rays showed a mild spondylolisthesis (Figure 2A and 2B).

Figure 1A: Pre-operative sagittal T2-weighted
MRI demonstrates adjacent segment disease.

Figure 1B: Pre-operative axial  T2-weighted
MRI demonstrates adjacent segment disease.

Figure 2A: Pre-operative flexion film
demonstrates mild listhesis at L3-L4.

Figure 2B: Pre-operative extension
film demonstrates mild listhesis at L3-L4.


Adjacent segment stenosis and disease of the lumbar spine

Suggest Treatment

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Selected Treatment

Minimally invasive lateral indirect decompression and fusion with stand-alone interbody device.

A single-stage, MIS lateral approach afforded adequate indirect decompresion and stabilization and obviated the need to open the previous posterior incision and remove the old hardware. Operative time was under two hours with minimal blood loss, and the patient was discharged on post-operative day one.

A growing body of literature supports the option of lateral lumbar interbody techniques for treatment of degenerative disease and deformity. It must be emphasized, however, that understanding the global spinal balance and spinopelvic parameters (best determined with 36" standing scoliosis films) is essential to integrate the lateral approach into the surgical plan. Whether to use stand-alone interbody devices, or in conjunction with lateral and posterior instrumentation relies on the appreciation of this global spinal balance.

Post-operative Imaging at 6 Months

Figure 3A: Post-operative flexion x-ray at 6 months.

Figure 3B: Post-operative extension x-ray at 6 months.


The patient had no post-operative complications and no thigh pain or parasthesias. Her symptoms drastically improved by her first post-operative visit, and at the most recent visit (6 months post-op) she was symptom free with a NPS of 0/10 in both the back and legs.

Case Discussion

This is a very interesting case of junctional stenosis in a patient with at least some significant loss of lumbar lordosis. As the author notes, the best assessment of sagittal alignment should be done with long-standing films assessing pelvic incidence, overall lumbar lordosis, and overall balance. We do not have this in this case. What remains to be answered is, “Will this strategy for treatment decrease the chance of further junctional degeneration?” The clinical results are excellent. I would also question the need for posterior stabilization, as the healing potential is challenged by the construct being placed adjacent to a solid fusion.

Community Case Discussion (2 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.

i've used this management strategy on multiple occasions and, like this case, have enjoyed good outcomes. i agree however with dr. albert's concern about possibly using posterior instrumentation. i've used the LDR cage with "fins" to try to effect some stability, however i'm not sure how much, if any, stability this provides. i've not seen any biomechanics data on the LDR cage with fins as to stability in all six planes. i'm interested if anyone has used the LDR and what their experience is. terry piper

I fully agree with Dr. Todd. The sagittal balance including pelvic parameters are missing in this discussion. However , concerning the strategy and the initial planing of treatment of this patient I'm very ceptic about the posterior fusion only, because of the horizontal instability. At the beginning I perconize 360 fusion, by TLIF, if you need any spine canal decompression, or an indirect decompression with OLIF technique plus percutaneous pedicular fixation (L4-L5 and L5-S1) . But concerning the actual discussion, my option could be anterior inter somatic fusion at the three levels (OLIF) and in posterior, I would expand the rigid fixation until L3-L4 and eventually I would consider a Dynamic pedicular fixation at the top (L2-L3). I'm happy for the patient, the result at 6 months FU is good, but unfortunately I believe it will deteriorate in the future. It depends of the sagittal unbalance manly, but I would like to know the result at 3 years FU. Thanks to Dr. Ali A. Bajj for this very nice discussion.


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