While spinal fusion has long been the “gold standard,” growing long-term data on adjacent segment disease is telling a different story on the best options for patients.
Four spine surgeons discuss how their conversations with patients have evolved along with the data.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
Next question: How is the growing body of data on adjacent segment disease changing how you counsel patients before index fusion procedures?
Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, June 23.
Question: How is the growing body of data on adjacent segment disease changing how you counsel patients before index fusion procedures?
Jason Billinghurst, MD. Palm Beach (Fla.) Orthopaedic & Spine Associates: Adjacent segment disease has become an increasingly important part of the preoperative discussion with patients considering spinal fusion, particularly in younger or more active individuals. As the long-term data continues to evolve, we now have a better understanding that while fusion can be highly effective for appropriately selected patients, altering the biomechanics of the spine increases stress at the levels above and below the fusion construct.
Because of this, my counseling process has become more individualized and focused on long-term spinal health rather than simply addressing the immediate pathology. I explain to patients that the goal of surgery is to relieve symptoms, improve function, and restore quality of life, but that every fusion carries the potential for future degeneration at adjacent levels. Importantly, I also emphasize that ASD is multifactorial and influenced not only by the fusion itself, but by factors such as age, genetics, preexisting degeneration, alignment, body habitus, smoking status, activity level and the overall condition of the spine at the time of surgery.
A growing body of evidence has reinforced the importance of preserving motion whenever appropriate. In carefully selected patients, motion-preserving technologies such as cervical or lumbar disc arthroplasty may help reduce biomechanical stress on adjacent levels while still effectively treating the underlying pathology. However, these procedures are not suitable for every patient, and the decision must ultimately be guided by anatomy, pathology, stability, and long-term durability.
The data has also heightened our attention to surgical planning and sagittal alignment. Modern spine surgery is no longer just about decompressing nerves or stabilizing a segment – it is about restoring physiologic alignment and minimizing the likelihood of future problems. Even small decisions regarding fusion length, implant selection, and alignment goals can influence long-term outcomes.
Ultimately, I believe patients appreciate transparency. I counsel them that no spinal surgery completely “stops the clock” on degeneration, but thoughtful patient selection, meticulous surgical technique, and consideration of motion-preserving options when appropriate can help optimize both short- and long-term outcomes.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: It has made me more explicit, more honest, and in a small but meaningful number of cases, more likely to recommend against fusion.
The data on adjacent segment disease are sobering. Depending on how you define it and how long you follow patients, radiographic adjacent segment degeneration is nearly universal after lumbar fusion. Clinically significant adjacent segment disease requiring reoperation occurs in a meaningful percentage of patients over a 10-year horizon. They’re not rare events, but an expected sequelae of altering spinal biomechanics, and we owe patients that information before the index operation.
I now explicitly tell patients that lumbar fusion is not a one-time intervention for most people who have it. I draw a diagram showing the mechanical stress redistribution that fusion creates. I discuss what we would do and what our options would be if they develop symptoms at an adjacent level in five years.
For younger patients, this conversation has become genuinely consequential. A 40-year-old with a two-level fusion faces a very different long-term trajectory than a 68-year-old with the same procedure. Age changes the calculus, and the adjacent segment disease literature has given me better language for that conversation.
In a small number of cases, this has led to a shared decision to pursue prolonged conservative management in patients who might previously have proceeded to fusion. That’s the right outcome of better data — not paralysis, but more honest calibration.
Siamak Yasmeh, MD. DISC Surgery Center (Tarzana and Marina Del Rey, Calif.): The growing body of data on adjacent segment disease has made preoperative counseling for fusion surgery more individualized. When discussing index fusion, I explain that while fusion can be highly effective for appropriate patients, it may increase stress at adjacent levels over time. At the same time, I emphasize that while radiographic changes of adjacent segment degeneration are common with aging, this does not necessarily translate into symptomatic disease or the need for additional surgery. That distinction is important for setting realistic expectations and avoiding unnecessary concern when future imaging demonstrates age-related changes. I spend more time discussing long-term spinal health, alignment preservation, and limiting fusion levels whenever possible. In select patients, motion-preserving options such as cervical disc arthroplasty and laminoplasty may also be part of the conversation and are my preferred approach to situations whenever possible.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The concept of accelerated adjacent segment degeneration from either cervical or lumbar surgery is well documented, expected and inquired by patient and family alike. Many patients investigate the need for additional fusion versus just reliance on a decompression following adjacent level failure (disease), after experiencing a fusion and its post-operative tribulations. Depending on the degree of degeneration, instability or alignment abnormalities will usually contour this discussion. A reflexive approach to an additional index fusion is passe, as motion x-rays and radio-isotopic bone scanning can assist with work-up and surgical strategies. Individual patient variance remains the mainstay of planning and execution.
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