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Surgical Treatment of Failed Back Surgery Syndrome due to Sagittal Imbalance

Jang, Jee-Soo, MD, PhD*; Lee, Sang-Ho, MD, PhD; Min, Jun-Hong, MD, PhD*; Kim, Seok Kang, MD*; Han, Kyoung-Mi, RN*; Maeng, Dae Hyeon, MD

doi: 10.1097/BRS.0b013e31815cde71

Study Design. Retrospective study of consecutive patient series.

Objective. To review the etiology of failed back surgery syndrome due to sagittal imbalance and radiographic and clinical results of surgical treatment of these patients who were treated with combined anterior and posterior arthrodesis.

Summary of Background Data. Sagittal imbalance after spinal fusion surgery may be a major source of pain and disability. Preventing iatrogenic sagittal imbalance should be a key objective during spinal fusion surgery.

Methods. Retrospective review of revision spine surgery due to sagittal imbalance treated with combined anterior and posterior spinal arthrodesis in the 19 patients. Outcome variables included radiographic measures of preoperative, postoperative, and follow-up films, and a clinical assessment using the Verbal Analogue Scale (VAS), Oswestry Disability Index, Macnab criteria, Satisfactory Index Instrument, and a review of postoperative complications.

Results. Mean age was 62 years (range, 49–74 years), and mean follow-up was 31 months (range, 24–37 months) for clinical and radiographic outcome variables. The mean preoperative sagittal imbalance was 116 (±65) mm, which improved to 32 mm (±29) after surgery. Mean lumbar lordosis was 15° (±20°) before surgery, and increased to 38° (±13°) at follow-up, an increase of 23°. The mean VAS improved from 7.2 (back pain), 6.8 (leg pain) before the surgery to 3 (back pain), 3.2 (leg pain) after the surgery (P < 0.0001). The mean Oswestry Disability Index scores improved from 62 (±11) before the surgery to 36 (±12) after the surgery (P < 0.0001). Excellent or good outcome was demonstrated in 16 patients (84.2%).

Conclusion. Most common causes of revision spine surgery due to sagittal imbalance were failure to enhance lumbar lordosis and adjacent disc degeneration after lumbar fusion surgery. These patients were effectively treated with a combined anterior and posterior arthrodesis. Following these surgical treatment, sagittal balance was generally improved with fair-to-good clinical outcomes, high patient satisfaction, and low perioperative complication rates.

Causes of sagittal imbalance after lumbar fusion in this study were included inadequate lumbar fusion surgery, proximal or distal adjacent disc degeneration, proximal vertebral body collapse without trauma, and posttraumatic thoracolumbar kyphosis without compensation of lumbar spine. These patients were effectively treated with a combined anterior and posterior arthrodesis.

From the Departments of *Neurosurgery and ‡Chest Surgery, Gimpo Airport Wooridul Spine Hospital, Seoul, Korea; and †Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea.

Acknowledgment date: April 24, 2007. Revision date: June 19, 2007. Acceptance date: June 20, 2007.

Supported by a grant from the Wooridul Spine Foundation.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Foundation funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Jee-Soo Jang, MD, PhD, Gimpo Airport Wooridul Spinal Hospital, 272-28, Gwahaedong, Gangseogu, Seoul, 157-822, Republic of Korea; E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.