ASD: More likely above or below?

[JScoli91]

Does anyone know if there is any data regarding ASD (Adjacent Segment Disease) as far as whether it is more common above or more common below a fusion? For example, a T only fusion you expect to a certain degree ASD in the L. If you fuse the L then would the ASD most likely continue below the L into your hips and other locations or is ASD possible in the C and shoulders?

Or is it more likely that if ASD were to occur in the C and shoulders above the T, it would have already happened if it was going to happen seeing as how it’s been 15+ years already with no issue?

I hope this all makes sense, I haven’t finished my coffee yet this morning so please bear with me.

[LindaRacine]

Does anyone know if there is any data regarding ASD (Adjacent Segment Disease) as far as whether it is more common above or more common below a fusion? For example, a T only fusion you expect to a certain degree ASD in the L. If you fuse the L then would the ASD most likely continue below the L into your hips and other locations or is ASD possible in the C and shoulders?

Or is it more likely that if ASD were to occur in the C and shoulders above the T, it would have already happened if it was going to happen seeing as how it’s been 15+ years already with no issue?

I hope this all makes sense, I haven’t finished my coffee yet this morning so please bear with me.

It's all dependent on which vertebra is the highest fused level and which vertebra is the lowest fused level, as well as the health of the discs above and below, and how level the vertebra are. Some people have ASD above and below.

[Pooka1]

https://pdfs.semanticscholar.org/c4e...186.1581549275

MedicinePublished in Orthopedics 2014
DOI:10.3928/01477447-20140728-08

Adjacent segment disease.

Sohrab S. Virk, Steven R. Niedermeier, +1 author Safdar N. Khan

EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Understand the forces that predispose adjacent cervical segments to degeneration. 2. Understand the challenges of radiographic evaluation in the diagnosis of cervical and lumbar adjacent segment disease. 3. Describe the changes in biomechanical forces applied to adjacent segments of lumbar vertebrae with fusion. 4. Know the risk factors for adjacent segment disease in spinal fusion. Adjacent segment disease (ASD) is a broad term encompassing many complications of spinal fusion, including listhesis, instability, herniated nucleus pulposus, stenosis, hypertrophic facet arthritis, scoliosis, and vertebral compression fracture. The area of the cervical spine where most fusions occur (C3-C7) is adjacent to a highly mobile upper cervical region, and this contributes to the biomechanical stress put on the adjacent cervical segments postfusion. Studies have shown that after fusion surgery, there is increased load on adjacent segments. Definitive treatment of ASD is a topic of continuing research, but in general, treatment choices are dictated by patient age and degree of debilitation. Investigators have also studied the risk factors associated with spinal fusion that may predispose certain patients to ASD postfusion, and these data are invaluable for properly counseling patients considering spinal fusion surgery. Biomechanical studies have confirmed the added stress on adjacent segments in the cervical and lumbar spine. The diagnosis of cervical ASD is complicated given the imprecise correlation of radiographic and clinical findings. Although radiological and clinical diagnoses do not always correlate, radiographs and clinical examination dictate how a patient with prolonged pain is treated. Options for both cervical and lumbar spine ASD include fusion and/or decompression. Current studies are encouraging regarding the adoption of arthroplasty in spinal surgery, but more long-term data are required for full adoption of arthroplasty as the standard of care for prevention of ASD.

[titaniumed]

The way I understand the terms or remember easily is that "Radiculopathy" is a set of several conditions that produce pain "before" fusion surgery.

And ASD, being the same basic thing with a set of several conditions "after" fusion surgery, and (Adjacent to the fusion mass)

Both of these terms are not specific and do not zero in on the actual cause. They do not define a disc herniation, nerve root impingement, or spondy, stenosis Etc. Its like saying the car was crashed and we don't know specifically what is wrong with the car. A combination definition. If you don't know exactly whats wrong, these terms leave it wide open.

Ok, so on ASD for a full fusion patient to the pelvis, for this definition, we only have to be concerned with what happens "above" our fusion mass. You could have a lumbar complication and it wont be defined as ASD or Radiculopathy. The problem will be specifically called out as something else. Surgeons are usually pretty good at diagnosing specific problems, I have seen this in the past.

Most full fusion patients are not fused above T2. (with rare exceptions) I have wondered about that, and think it has to do with the first rib. It connects and protects the disc. They have to resect the rib to get in there. See paper below.

I have attached a paper on a rare case of a T1-T2 herniation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779266/

Another thing of interest is the fact that thoracic herniation's are not as common as the classic L4-5 L5-S1 or C5-6, C6-7 herniation levels. Lumbar is the most common, followed by the C5-6, C6-7 levels in the neck. Protection from the ribs? I have read that thoracic herniation's are due mostly to trauma related events....

Since JScoli is already fused to T2, I don't see any reason to worry about this.....You should do fine since you are 29 year old. Age is a big factor. (for everything!)

Ok, so I get all done with serious scoliosis surgery and then you know what is next? Periodontal disease....(The gums) I have been going mental on the dental, and 51% of everyone ends up with some sort of perio disease when they get up around age 60. Flossing ONLY gets 1-2 mm below the gum line, and if you have been root planed, your chances are higher for perio problems when you get older. Water picking with Listerine, diluted Hydrogen Peroxide are methods of fighting this. If the bacteria gathers below your flossing zone, you have perio disease. And it hurts like hell. OMG. I have great pearly whites! Its what happens below that's the problem. I am on antibiotics and staph does travel in the body....and I have a little hardware so its concerning....(smug face)

Do you save teeth, or pull them? That's my question. Will I have to go through a series of tooth pulls (molars) to avoid infection? Can we be infected and don't know it?

Ed

[jackieg412]

Ed i would say save your teeth. A good periodontist should be able to get it under control. There are many treatments that can be used. There isn't anything like your own teeth.

[LindaRacine]

The way I understand the terms or remember easily is that "Radiculopathy" is a set of several conditions that produce pain "before" fusion surgery.

And ASD, being the same basic thing with a set of several conditions "after" fusion surgery, and (Adjacent to the fusion mass)

Huh? I'm totally confused.

Not sure what radiculopathy has to do with the subject, but radiculopathy simply implies a pinched nerve. It can occur before, after, or have nothing to do with surgery.

Adjacent segment disease is defined as degeneration of the spine above or below a fusion.

--Linda

[titaniumed]

Linda, sorry, I guess I should have added the links and did that post differently...

https://www.ncbi.nlm.nih.gov/pubmed/25102498

Adjacent segment disease (ASD) is a broad term encompassing many complications of spinal fusion, including listhesis, instability, herniated nucleus pulposus, stenosis, hypertrophic facet arthritis, scoliosis, and vertebral compression fracture.
================================================== ================================================== ===============================
Radiculopathy most often is caused by mechanical compression of a nerve root usually at the exit foramen or lateral recess. It may be secondary to degenerative disc disease, osteoarthritis, facet joint degeneration/hypertrophy, ligamentous hypertrophy, spondylolisthesis, or a combination of these factors.[2] Other possible causes of radiculopathy include neoplastic disease, infections such as shingles, HIV, or Lyme disease, spinal epidural abscess, spinal epidural hematoma, proximal diabetic neuropathy, Tarlov cysts, or, more rarely, sarcoidosis, arachnoiditis, tethered spinal cord syndrome, or transverse myelitis.

https://en.wikipedia.org/wiki/Radiculopathy
================================================== ================================================== ==============================
I included radiculopathy because it "also" is one of these medical terms that is so broad that includes multiple causes.
.
With ASD, are we talking about a herniation, or lithesis? These are 2 separate issues.

With Radiculopathy, it explains about the compression of a nerve root, but why include something like arachnoiditis in with this? I have been diagnosed with radiculopathy, but not by my surgeon. He was always very specific. Multiple causes are lumped into each definition.

There are countless ASD studies online. I have not seen any pertaining to a full fusion to pelvis that addresses "above" our fusion mass. You will see studies of single level lumbar cases, above and below, 2 levels etc. You will see cervical studies, single and multiple level fusions, but these cases are not "scoliosis specific". Multiple levels also changes biomechanics of scoliosis.

I have seen studies with 19 patients over a broad age range. They need to have standards on the amounts of patients and age ranges closer than 25 years. Perhaps every 5 years.

Its like doing a study with 10 patients from age 1-100. A study titled "Back Pain". What is back pain? This is about as wide open as it gets. It includes everything under the sun. Its nice to be more specific, right?

Informed decision making can be especially difficult with scoliosis. Online data is all over the place, and its really hard to draw conclusions on specific questions. It makes no sense worrying about things that are out of our control. I had my surgeries 12 years ago, and I don't have problems with ASD. Neck problems, yes, but that was present before my surgeries. I will reach up and pull my fusion mass forward with my fingers and look up and get an occasional pop. It feels good and relieves tension in the top joint.

Jackie, I am real close to going to an oral surgeon for more fun, fun, fun. I am not feeling good at all.

Ed

[Pooka1]

Does anyone know if there is any data regarding ASD (Adjacent Segment Disease) as far as whether it is more common above or more common below a fusion? For example, a T only fusion you expect to a certain degree ASD in the L. If you fuse the L then would the ASD most likely continue below the L into your hips and other locations or is ASD possible in the C and shoulders?

Or is it more likely that if ASD were to occur in the C and shoulders above the T, it would have already happened if it was going to happen seeing as how it’s been 15+ years already with no issue?

I hope this all makes sense, I haven’t finished my coffee yet this morning so please bear with me.

1. ASD refers only to the spine (segment = vertebra). Shoulders and hips are irrelevant to ASD.

2. The likelihood of ASD below a fusion is a function of where the fusion ends and how straight the lumbar is driven by the T fusion. That's for a non-structural lumbar curve. If the unfused lumbar is structural, I am guessing there is a 100% chance of developing ASD below the fusion.

3. ASD above a fusion I think is synonymous with proximal junctional kyphosis (PJK). I have seen papers trying to suss out why certain people get PJK and others don't. I don't think this research is very advanced.

4. I don't think it is known whether extending a fusion distally can induce PJK.