Define pseudarthrosis

Pseudarthrosis is defined as failure to obtain a solid bony union after an attempted spinal fusion. The time between initial surgery and diagnosis of pseudarthrosis is variable. One year following initial surgery is a reasonable and accepted interval for determining fusion success for short segment cervical and lumbar fusions. In certain cases, a patient's symptoms and imaging studies suggest the diagnosis of pseudarthrosis as early as 6 months following initial surgery. However, in patients undergoing multilevel spinal deformity instrumentation procedures, pseudarthrosis may not present until several years following index surgery. The diagnosis of pseudarthrosis is suggested by the presence of continued axial pain and the absence of bridging trabecular bone on plain radiographs. Other findings that suggest the presence of pseudarthrosis include abnormal motion on flexion-extension radiographs, loss of spinal deformity correction, and spinal implant loosening or failure.

Table 34-1. Classification of Problems after Spinal Decompression Procedures

1. LACK OF IMPROVEMENT IMMEDIATELY AFTER SURGERY WITH PERSISTENT OR UNCHANGED RADICULAR SYMPTOMS

A. Wrong Preoperative Diagnosis

Tumor

Psychosocial causes

Infection

Discogenic pain syndrome

Metabolic disease

Decompression performed too late

B. Technical Error

Surgery performed at wrong level(s)

Failure to treat both spinal stenosis and disc protrusion when necessary

Inadequate decompression performed

Conjoined nerve root

Missed disc fragment

2. TEMPORARY RELIEF WITH RECURRENCE OF PAIN

A. Early Recurrence of Symptoms (within 6 Weeks)

Hematoma

Infection

Meningeal cyst

Facet or pars fracture

B. Midterm Failure (6 Weeks to 6 Months)

Recurrent disc herniation

Arachnoiditis

Stress fracture of pars interarticularis

Unrealistic patient expectations regarding surgical outcome

Battered root syndrome

C. Long-Term Failure (> 6 Months)

Recurrent stenosis

Adjacent-level stenosis

1 Segmental spinal instability

Adapted from Kostuik JP. The surgical treatment of failures of laminectomy. Spine State Art Rev 1997;11:509-38.

Table 34-2. Classification of Problems after Spinal Fusion Procedures

TIME OF APPEARANCE

BACK PAIN PREDOMINANT

LEG PAIN PREDOMINANT

Early (Weeks)

Infection

Neural Impingement by Fixation Devices

Wrong level fused

Foraminal stenosis due to change in spinal alignment (e.g. after spinal osteotomy)

Insufficient levels fused

Psychosocial distress

Midterm (Months)

Pseudarthrosis

Neural Compression Due to Pseudarthrosis

Adjacent-level degeneration

Adjacent-level degeneration

Sagittal imbalance

Graft donor site pain

Graft donor site pain

Inadequate reconditioning

Implants loose, displaced or broken

Long-Term (Years)

Pseudarthrosis

Adjacent-Level Stenosis

Adjacent-level instability

Adjacent-level disc herniation

Acquired spondylolysis

Compression fracture adjacent to fusion

Adjacent level degeneration

Abutment syndrome

Adapted from Kostuik JP. Failures after spinal fusion. Spine State Art Rev 1997;11:589-650.

Adapted from Kostuik JP. Failures after spinal fusion. Spine State Art Rev 1997;11:589-650.

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Dealing With Back Pain

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