Study Design Retrospective cohort study. Objectives To identify imaging predictors on pre- and perioperative imaging that are associated with a future revision surgery for adjacent segment disease (ASD) following lumbar fusion. Methods Patients undergoing open posterior lumbar fusion between 2014-2022 were followed-up for &gt;2-year. The initial MRI was evaluated for disc degeneration by Pfirrmann (grade 1-5); Modic changes (0-3); as well as fatty infiltration and functional cross-sectional area (fCSA) of the multifidus, erector spinae, and psoas. Spinopelvic alignment was measured pre- and postoperatively. Results Of 216 patients, 14.8% (n = 32) required revision surgery for ASD in the further course. There were no significant differences in Modic changes or Pfirrmann grades between the ASD group and controls. Fatty infiltration was significantly higher in the ASD group for both the erector spinae (40.5% vs 36.9%, P = 0.043) and multifidus muscles (61.0% vs 53.9%, P = 0.003). Additionally, the multifidus fCSA was smaller in patients who developed ASD (5.7 cm 2 vs 6.7 cm 2 ). Pre- and postoperative spinopelvic parameters were not significantly different between groups, and no other MRI measurements showed a significant difference. In a multivariable logistic regression model adjusting for age and sex, multifidus fatty infiltration emerged as the only significant predictor of ASD revision surgery ( P = 0.004). Patients with more than 58% multifidus fatty infiltration had over double the risk of developing ASD (OR 2.7, 95% CI: 1.1-6.5, P = 0.032). Conclusions Multifidus fatty infiltration is the key imaging predictor for the development of ASD requiring surgical revision. Disc degeneration and spinopelvic alignment appear to have less impact.

Multifidus Degeneration: The Key Imaging Predictor of Adjacent Segment Disease