Paraspinal Muscle Quality and Adjacent Facet Joint Degeneration as Significant Predictors of ASDis Revision After Lumbar Fusion

Paraspinal Muscle Quality and Adjacent Facet Joint Degeneration as Significant Predictors of ASDis Revision After Lumbar Fusion | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Paraspinal Muscle Quality and Adjacent Facet Joint Degeneration as Significant Predictors of ASDis Revision After Lumbar Fusion Dandan li, Peng Gao, Yingjuan Chang, Xing Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9149969/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Posterior lumbar interbody fusion (PLIF) combined with pedicle screw internal fixation is widely used for treating lumbar degenerative diseases. However, adjacent segment disease (ASDis) requiring revision surgery is a severe complication, and few studies have focused on this complication. Paraspinal muscle mass loss is associated with lumbar diseases and poor postoperative prognosis, but its relationship with ASDis revision remains unclear Purpose To explore the relationship between paraspinal muscle quality and ASDis revision after lumbar fusion and identify its independent risk factors. Methods Patients who underwent revision surgery for the development of ASD at our hospital were enrolled. To evaluate the risk factors for revision, we selected a control group. Each patient in the control group was matched by age, sex, height, weight, BMI, number of fused segments and follow-up duration with a patient in the revision group. Paraspinal muscle parameters, including the cross-sectional area (CSA), functional cross-sectional area (FCSA), CSA-vertebral index (CSA-VI), FCSA-vertebral index (FCSA-VI), and FCSA/CSA ratio, at the third lumbar (L3) and fourth lumbar (L4) levels were measured via MRI. Receiver operating characteristic (ROC) curves and logistic regression were used for analysis. Results At the L3 and L4 levels, the FCSA, FCSA-VI and FCSA/CSA ratio of the paraspinal, erector spinae and multifidus muscles were significantly lower in the revision group ( P < 0.05). The L4 paraspinal muscle FCSA/CSA ratio had the highest area under the curve (AUC) (0.942). Preoperative adjacent facet joint degeneration was greater in the revision group ( P < 0.05). Logistic regression revealed that L4 paraspinal muscle FCSA/CSA ratio (odds ratio = 0.731, P < 0.001) and preoperative adjacent facet joint degeneration (odds ratio = 4.664, P = 0.023) were independent risk factors. Conclusion Decreased paraspinal muscle quality is associated with ASDis revision. L4 paraspinal muscle FCSA/CSA and preoperative adjacent facet joint degeneration can predict ASDis revision. Conclusion: A decreased paraspinal muscle mass is associated with ASDis revision. L4 paraspinal muscle FCSA/CSA ratio and preoperative adjacent facet joint degeneration are independent risk factors for ASDis revision. Lumbar fusion Adjacent segment disease revision Paraspinal muscle quality Magnetic resonance imaging Figures Figure 1 Figure 2 Introduction Lumbar fusion is currently the main treatment for various lumbar pathologies, including degenerative lumbar instability, degenerative disc disease, severe spondylolisthesis, lumbar spinal stenosis, and lumbar deformity[1,2]. Lumbar fusion can be classified into posterior, anterior, and transforaminal lumbar interbody fusion. Among these approaches, posterior lumbar interbody fusion (PLIF) with pedicle screw fixation is widely utilized clinically because of its high safety profile and convenient operability[3,4]. While often a successful procedure, lumbar fusion is not without complications. One known complication is adjacent segment disease (ASDis)[5]. It is thought that abnormal mechanical loading and increased motion through proximal or distal segments can accelerate degenerative changes in unfused segments[6,7,8]. The development of ASD significantly impairs the quality of life of patients following lumbar fusion surgery, and in severe cases, it necessitates revision surgery on adjacent segments. Therefore, identifying the risk factors for ASDis during revision surgery is highly important. Paraspinal muscle quality deterioration is characterized primarily by paraspinal muscle atrophy, which is specifically characterized by reduced paraspinal muscle mass and increased fat infiltration. Currently, the clinical utility of imaging-based evaluation of paraspinal muscle quality deterioration as a prognostic marker has been increasingly validated across multiple surgical subspecialties, including metastatic diseases, trauma, and fractures[9,10,11,12]. Despite extensive research focused on identifying potential determinants of revision surgery, the association between paraspinal muscle quality and revision surgery remains inadequately understood. Therefore, by comparing paraspinal muscle quality based on preoperative imaging data between patients who underwent revision surgery and those who did not undergo revision surgery due to the absence of clinical surgical indications, this study aimed to explore the relationships between changes in paraspinal muscle quality and revision after lumbar fusion, as well as to analyze other imaging risk factors for revision surgery. Materials and methods Patient selection The studies involving human participants were reviewed and approved by the Ethics Committee of The First Affiliated Hospital of Dalian Medical University, and this research was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study retrospectively reviewed the medical records and imaging data of all patients who underwent PLIF with screw fixation for degenerative spinal diseases between January 2007 and January 2023. The inclusion criterion was a preoperative diagnosis of degenerative lumbar diseases, including spinal stenosis, degenerative lumbar spondylolisthesis, and lumbar disc herniation. The exclusion criteria were as follows: (1) history of other nondegenerative diseases affecting the spinal structure, such as spinal tumors, spinal infections, and spinal fractures; (2) previous history of paraspinal muscle injury or infection; (3) comorbidities of metabolic diseases that may affect paraspinal muscle metabolism, including diabetes mellitus, thyroid dysfunction, and hyperuricemia; and (4) incomplete lumbar imaging data. During the study period, 957 patients underwent PLIF with screw fixation, among whom 41 patients who met the aforementioned exclusion criteria were excluded. Ultimately, 916 patients were included in the retrospective analysis, 41 of whom underwent secondary revision surgery and were assigned to the revision surgery group. Surgical indications for ASD revision: Severe clinical symptoms (low back pain, radicular pain or numbness, intermittent claudication, etc.) that significantly impair patients' daily living activities and fail to respond to 3 months of conservative treatment. To identify factors associated with revision surgery, 41 patients who underwent single PLIF with pedicle screw fixation were selected as the control group via propensity score matching (PSM). These patients were matched to the revision surgery group for age, sex, body mass index (BMI), number of fused segments, and follow-up duration. MRI equipment and scanning parameters A GE 3.0T Signa HDxt scanner was used, with a spinal coil for image acquisition. The scanning sequences included sagittal T1-weighted (T1W), sagittal T2-weighted (T2W), sagittal T2W fat suppression, and axial T2W. Axial T2W images were analyzed, with a repetition time/echo time (TR/TE) of 2900–4880 ms/102–120 ms, a field of view (FOV) of 18×18–22×22 cm, a slice thickness of 4.0 mm, and a 320×256 matrix. For the sagittal T1W images, the TR/TE was 300–900 ms/7–15 ms, the FOV was 32×32 cm, the slice thickness was 4.0 mm, and the matrix width was 320×224. CT and X-ray equipment and parameters Lumbar CT images were obtained via a SIEMENS Emotion 16-slice spiral CT scanner or a GE Light speed 16-slice spiral CT scanner with a tube voltage of 120 kV, a tube current of 240–320 mAs, a slice thickness of 1 mm, a slice spacing of 1 mm, a rotation speed of 0.6–0.7 s, a pitch of 0.9–1.5 mm, and a matrix of 380×380. Lumbar lateral X-ray images were taken via SIEMENS Aristos MX or SIEMENS Aristos VX digital X-ray equipment, with a tube voltage of 81 kV and a tube current of 40 mAs. 4. Data Measurement 4.1 Measurement of Paraspinal Muscles Preoperative lumbar axial T2WI images were exported in DICOM format, and ImageJ software (version 1.53u, National Institutes of Health, USA) was used to analyze the images at the level of the lower endplates of the 3rd and 4th lumbar vertebrae. These two levels were selected because the maximum cross-sectional area of the psoas major muscle is located at the L4/5 level, the maximum cross-sectional areas of the multifidus muscle and erector spinae muscle are between the L3/4 and L4/5 levels [13], and the optimal level was selected by comparison. Two radiologists with more than 2 years of work experience who were familiar with paraspinal muscle anatomy delineated the region of interest (ROI) and measured the paraspinal muscle data in a double-blind manner. The methods for ROI delineation and data measurement of paraspinal muscles were as follows: ImageJ software was used to delineate the psoas major muscle (PM), erector spinae muscle (RS), and multifidus muscle (MF) along their edges to obtain the total CSA of the PM, ES, MF, and PSM (i.e., the sum of the erector spinae muscle and multifidus muscle) (as shown in Figure 1). Threshold extraction technology was used to obtain the pure muscle area without fat of each paraspinal muscle, namely, the functional cross-sectional area (FCSA) (as shown in Figure 1). Meanwhile, the vertebral cross-sectional area (VCSA) at the corresponding level was measured. To eliminate the influence of body size on the paraspinal muscle area, the muscle-vertebra index was used to standardize the CSA and FCSA, the total cross-sectional area-vertebra index (CSA-VI) and functional cross-sectional area-vertebra index (FCSA-VI) (CSA-VI=100×CSA/VCSA, FCSA-VI= 100×FCSA/VCSA) were obtained, and the FCSA/CSA ratio was calculated. The specific method of threshold extraction technology was as follows: to avoid adipose tissue within the CSA of paraspinal muscles, 4--6 ROIs containing only muscle tissue were selected, the maximum gray value measured among them was taken as the maximum threshold for distinguishing muscle tissue from adipose tissue, and the minimum threshold was set to 0. The area within this threshold range was the FCSA [14]. 4.2 Other Measurement Indicators (1) Facet joint degeneration: The degree of facet joint degeneration in adjacent segments was graded via the Weishaupt classification system on the basis of lumbar CT images. Two radiologists with more than 2 years of work experience performed the grading, and inconsistent cases were determined by joint consultation. The specific Weishaupt classification was as follows: Grade 0: normal facet joint space (2–4 mm in width); Grade 1: narrowed facet joint space (<2 mm) and/or small osteophyte formation and/or mild hypertrophy of the articular processes; Grade 2: narrowed facet joint space and/or moderate osteophyte formation and/or moderate hypertrophy of the articular processes and/or mild subchondral bone destruction; Grade 3: narrowed facet joint space and/or large osteophyte formation and/or severe hypertrophy of the articular processes and/or severe subchondral bone destruction or cystic changes [15]. (2) MRI-based vertebral bone quality (VBQ) score: the ratio of the average signal intensity of the 1st to 4th lumbar vertebrae on the mid-sagittal T1WI to the cerebrospinal fluid signal intensity at the level of the 3rd lumbar vertebra, which can reflect vertebral bone quality and assess vertebral osteoporosis [16]. The specific ROI delineation is shown in Figure 2. During measurement, if the mid-sagittal plane is covered by mixed signals such as the venous plexus, the left or right parasagittal plane is used; if there are still mixed signals in the parasagittal plane, the vertebra is discarded; if the cerebrospinal fluid signal at the level of the 3rd lumbar vertebra is covered due to stenosis or other reasons, the cerebrospinal fluid signal at the level of the 2nd or 4th lumbar vertebra is used. Two radiologists with more than 2 years of work experience performed the measurements independently in a double-blinded manner. (3) CT-based vertebral Hounsfield unit (HU) value: The 1st lumbar vertebra was selected as the target vertebra in this study because it is the first vertebra not connected to the ribs, is easy to identify, and is less prone to degeneration than other vertebrae are. ROIs were delineated at the middle level of the 1st lumbar vertebra, the first level below the upper endplate, and the first level above the lower endplate. During delineation, structures such as the cortical bone and venous plexus were avoided, and the average HU value of the three levels was finally calculated [17]. Two radiologists with more than 2 years of work experience performed the measurements independently in a double-blinded manner. Lumbar lordosis (LL): The angle between the upper endplate of the 1st lumbar vertebra and the upper endplate of the sacral vertebra, reflecting sagittal spinal balance. Preoperative LL and postoperative LL were measured on preoperative and postoperative lumbar X-ray images of patients, respectively. Two radiologists with more than 2 years of work experience performed the measurements independently in a double-blinded manner. Statistical analysis. For statistical analysis and model development, SPSS 27.0 and MedCalc software (version 20.022) were used. Interobserver consistency for all the quantitative measurements was evaluated via the intraclass correlation coefficient (ICC). Categorical variables, including sex and the number of fused segments, were analyzed with Pearson’s chi-square test. Normality testing was conducted for all continuous variables prior to subsequent analyses. Continuous variables that conformed to a normal distribution are expressed as the means ± standard deviations and were compared via the independent samples t test, whereas those that did not meet the normality assumption were analyzed via nonparametric tests. For paraspinal muscle parameters with statistically significant differences between groups, receiver operating characteristic (ROC) curves were constructed to calculate the area under the curve (AUC), and the optimal cutoff values, sensitivity, and specificity were determined. The Delong test was applied to compare AUC values among different parameters. Univariate analyses, including Pearson’s chi-square test and the independent samples t test as appropriate, were performed to assess the differences in facet joint degeneration grades, VBQ values, HU values, preoperative LL values, and postoperative LL values between the experimental group and the control group. Logistic regression analysis was then conducted incorporating paraspinal muscle parameters and positive results from the univariate analysis to identify independent predictors of ASD revision. A P value of <0.05 was considered to indicate statistical significance. Results Comparison of basic patient data A total of 82 patients were retrospectively analyzed in this single-center study. The patients were divided into two groups: the revision group (41 patients) and the control group (41 patients). Table 1 summarizes the basic data of these groups, including age, sex, height, weight, BMI, number of fused segments and follow-up duration. No significant differences were detected between the two groups ( P >0.05). Table 1 Baseline characteristics of the study population revision and control groups Variable Different groups P Revision group（n=41） Control group（n=41） Age (yrs) 64.83±9.67 63.54±9.23 0.537 Height（cm） 168.83±8.01 166.73±5.85 0.338 Weight（kg） 73.96±10.76 71.55±11.92 0.180 BMI (kg/m 2 ) 25.88±2.84 25.70±3.87 0.806 Sex 1.000 Male 24 24 Female 17 17 Number of fused segments 1.000 1 23 23 2 18 18 Follow-up duration（mth） 53（24，93） 55（30，92） 0.700 Radiological characteristics Comparisons of the quantitative parameters of the paraspinal muscles between the revision group and the control group in patients who underwent lumbar fusion at the L3 and L4 levels are shown in Tables 2 and 3, respectively. At the L3 and L4 levels, there were no statistically significant differences in the CSA, CSA-VI, FCSA, FCSA-VI, or FCSA/CSA ratio of the psoas major muscle between the two groups ( P >0.05). No statistically significant differences were detected in the CSA or CSA-VI of the paravertebral muscle group, erector spinae muscles, or multifidus muscles between the two groups ( P >0.05). The FCSA, FCSA-VI, and FCSA/CSA ratios of the paravertebral muscle group in the revision group were significantly lower than those in the control group ( P <0.05). The FCSA, FCSA-VI, and FCSA/CSA ratios of the erector spinae muscles in the revision group were significantly lower than those in the control group ( P <0.05). The FCSA, FCSA-VI, and FCSA/CSA ratios of the multifidus muscles in the revision group were significantly lower than those in the control group. Table 2 Comparison of paraspinal muscle parameters at the L3 level between patients who underwent ASDis revision surgery and those who did not undergo revision surgery after lumbar fusion revision group （n=41） control group （n=41） t P L3 CSA(mm 2 ) PS 1704.85±650.28 1701.83±590.76 0.022 0.982 PVM 4857.16±1013.18 4573.16±935.45 1.319 0.191 ES 3578.01±880.29 3348.07±750.12 -0.960 0.337 MF 1279.58±260.39 1225.09±292.81 0.890 0.376 L3 FCSA(mm 2 ) PS 1510.85±620.55 1519.84±606.40 -0.066 0.947 PVM 2599.51±1034.20 3346.14±790.79 -3.672 ＜ 0.001 ES 2063.46±821.13 2546.30±610.42 -3.022 0.003 MF 531.37±267.83 802.28±248.31 -4.750 ＜ 0.001 L3 CSA-VI(%) PS 101.88±33.93 107.79±33.55 -0.793 0.430 PVM 295.61±59.66 293.25±65.64 -0.190 0.849 ES 217.71±51.49 214.79±53.18 -0.107 0.915 MF 77.92±15.90 78.46±19.26 -0.139 0.890 L3 FCSA-VI(%) PS 90.23±32.75 95.97±34.02 -0.778 0.439 PVM 157.87±58.34 215.72±59.63 -4.478 ＜ 0.001 ES 124.49±45.14 164.18±46.99 -3.898 ＜ 0.001 MF 32.18±15.43 51.68±16.82 -5.470 ＜ 0.001 L3 FCSA/CSA ratio(%) PS 87.68±6.90 88.17±7.61 -0.304 0.734 PVM 52.64±15.51 73.75±13.99 -6.472 ＜ 0.001 ES 56.85±15.11 76.67±12.97 -6.372 ＜ 0.001 MF 40.98±17.55 66.09±17.24 -6.535 ＜ 0.001 Table 3 Comparison of paraspinal muscle parameters at the L4 level between patients who underwent ASDis revision surgery and those who did not undergo revision surgery after lumbar fusion revision group（n=41） control group （n=41） t P L4 CSA(mm 2 ) PS 2244.22±788.77 2143.49±649.59 0.631 0.530 PVM 4641.20±744.30 4361.25±980.76 1.456 0.149 ES 2833.96±617.36 2651.01±679.92 1.243 0.214 MF 1815.40±321.11 1710.26±399.80 1.313 0.193 L4 FCSA(mm 2 ) PS 1961.27±765.45 2083.89±630.58 -0.792 0.431 PVM 2328.29±571.83 2972.09±747.25 -4.067 ＜ 0.001 ES 1704.64±461.61 1943.95±554.91 -1.994 0.046 MF 687.45±355.85 1028.14±267.09 -4.903 ＜ 0.001 L4 CSA-VI(%) PS 141.91±40.11 142.72±37.06 -0.096 0.924 PVM 303.01±58.52 297.16±76.85 0.388 0.699 ES 185.96±49.49 181.10±54.43 0.371 0.711 MF 117.58±19.32 116.13±29.08 0.015 0.988 L4 FCSA-VI(%) PS 124.57±41.07 138.76±35.97 -1.665 0.100 PVM 151.00±37.16 202.81±56.90 -4.882 ＜ 0.001 ES 112.02±34.65 132.76±42.11 -2.447 0.017 MF 43.04±20.45 69.91±19.65 -6.065 ＜ 0.001 L4 FCSA/CSA ratio(%) PS 87.39±11.86 97.28±1.71 -5.285 0.762 PVM 49.99±8.59 68.22±7.63 -10.149 ＜ 0.001 ES 59.88±7.72 73.30±8.01 -7.726 ＜ 0.001 MF 37.19±17.39 60.34±9.12 -7.752 ＜ 0.001 The results of Delong's test for comparing the area under the curve (AUC) of each quantitative parameter between the L3 and L4 levels are shown in Table 4. The AUC of the FCSA/CSA ratio of the paravertebral muscle group at the L4 level was significantly greater than that at the L3 level ( P <0.05). The results of the ROC curve analysis for each parameter are presented in Table 5. At the L4 level, the AUC values of the paravertebral muscle group FCSA, erector spinae muscle FCSA, multifidus muscle FCSA, paravertebral muscle group FCSA-VI, erector muscle group FCSA-VI, multifidus muscle FCSA-VI, paravertebral muscle group FCSA/CSA ratio, erector spinae muscle FCSA/CSA ratio, and multifidus muscle FCSA/CSA ratio were 0.761, 0.621, 0.781, 0.773, 0.651, 0.836, 0.942, 0.881, and 0.869, respectively. Delong's test revealed that the AUC of the paravertebral muscle group FCSA/CSA ratio was significantly greater than that of the other paraspinal muscle parameters ( P <0.05). Therefore, the FCSA/CSA ratio of the paravertebral muscle group at the L4 level was identified as a potential predictor for the revision of ASDis after lumbar fusion. Table 4 Comparison of the AUCs of paraspinal muscle parameters at the L3 and L4 levels AUC(95%CI) p L3 L4 FCSA(mm 2 ) PVM 0.730(0.621-0.822) 0.761(0.654- 0.848) 0.546 ES 0.707(0.596-0.803) 0.621(0.514-0.732) 0.175 MF 0.786(0.682- 0.869) 0.781(0.676- 0.865) 0.922 FCSA-VI(%) PVM 0.755(0.647-0.843) 0.773(0.667-0.858) 0.792 ES 0.735(0.626- 0.826) 0.651(0.538- 0.753) 0.248 MF 0.810(0.709 -0.888) 0.836 (0.738-0.909) 0.668 FCSA/CSA ratio (%) PVM 0.846(0.749-0.916) 0.942(0.867-0.981) 0.026 ES 0.843(0.746-0.914) 0.881(0.791-0.942) 0.454 MF 0.844(0.747-0.915) 0.869(0.776-0.933) 0.642 Table 5 ROC curve analysis of paraspinal muscle parameters at the L4 level AUC(95%CI) SE P Cut off Sensitivity（%） Specificity（%） L4 FCSA(mm 2 ) PVM 0.761(0.654- 0.848) 0.054 <0.001 2383.194 68.29% 90.24% ES 0.621(0.514-0.732) 0.062 <0.001 1574..353 53.66% 70.73% MF 0.781(0.737- 0.908) 0.053 <0.001 842.711 73.17% 82.93% L4 FCSA-VI(%) PVM 0.773(0.667-0.858) 0.052 <0.001 154.526 63.41% 82.93% ES 0.651(0.538- 0.753) 0.061 <0.001 117.218 63.41% 65.85% MF 0.836 (0.738-0.909) 0.045 <0.001 49.604 70.73% 90.24% L4 FCSA/CSA ratio (%) PVM 0.942(0.867-0.981) 0.025 <0.001 56.612 85.37% 92.68% ES 0.881(0.791-0.942) 0.036 <0.001 63.954 75.61% 87.80% MF 0.869(0.776-0.933) 0.042 <0.001 50.512 78.05% 92.68% The results of the univariate analysis of preoperative adjacent segment facet joint degeneration grade, preoperative LL, postoperative LL, the VBQ score, and the vertebral body HU value between the revision group and the nonrevision group are shown in Table 6. Among these indicators, no statistically significant differences were observed in preoperative LL, postoperative LL, the VBQ score, or the HU value between the two groups ( P >0.05). The grade of preoperative adjacent segment facet joint degeneration in the revision group was significantly greater than that in the control group ( P <0.05). Table 6 Univariate analysis of other measured indicators between the revision group and the control group revision group （n=41） control group （n=41） P Facet joint degeneration 0.019 0 1 3 1 9 21 2 26 14 3 5 3 Preoperative LL 31.029±8.777 30.234±9.064 0.688 Postoperative LL 34.650±8.015 33.761±8.430 0.626 VBQ 3.228±0.775 3.531±0.981 0.125 HU value 127.340±30.929 130.926±36.056 0.630 Logistic regression analysis of risk factors for revision surgery for ASDis On the basis of the results of univariate analysis and ROC curve analysis, the paraspinal muscle FCSA/CSA ratio and preoperative degenerative grading of facet joints at adjacent segments were included in the logistic regression analysis. The results are presented in Table 7. According to the logistic regression model, the paraspinal muscle FCSA/CSA ratio (OR 0.731; 95% CI 0.633–0.844; P <0.001) and preoperative degenerative grade of adjacent segment facet joints (OR 4.664; 95% CI 1.235–17.617; P =0.023) were identified as independent predictors for the occurrence of ASDis revision surgery. Table 7 Logistic regression analysis of risk factors for ASDis revision surgery B SE Wald value OR 95%CI P L4 PVM FCSA/CSA ratio -0.313 0.073 18.367 0.731 0.633-0.844 <0.001 Facet joint degeneration 1.540 0.678 5.157 4.664 1.235-17.617 0.023 Interobserver reliability The consistency of the measurements of paraspinal muscle parameters, VBQ scores, vertebral body HU values, preoperative LL, and postoperative LL by the two observers was good (ICC: 0.820–0.992). Discussion Paraspinal muscles are key contributors to spinal stability. In recent years, studies investigating the relationship between decreased paraspinal muscle quality and adverse outcomes after lumbar surgery have reported that preoperative paraspinal muscle atrophy and increased fat infiltration can predict postoperative dysfunction, low back pain, and various complications and may also be associated with the risk of revision lumbar surgery[18]. ASDis is a common complication following lumbar fusion that impairs patients' quality of life and may require revision surgery in severe cases. This study controlled for the influence of confounding factors such as age, sex, BMI, number of fused segments, and follow-up duration via propensity score matching. On the basis of preoperative MR images, we analyzed the relationships between the quality of the PM, ES, MF, and PSM and ASDis after PLIF with pedicle screw fixation. We found no significant differences in the preoperative PM CSA, FCSA, CSA-VI, FCSA-VI, or FCSA/CSA ratio between the revision group and the control group. The PM is the main muscle of the anterior group of lumbar paraspinal muscles, originating from and spanning multiple lumbar vertebral segments [12]. The bilateral PM muscles participate in lumbar lateral flexion through axial compression and coordinated interactions but play a minor role in maintaining lumbar segmental stability. In addition, the PM is involved in hip joint movement [19, 20]. The lack of association between PM quality deterioration and the occurrence of postlumbar fusion ASDis may be attributed to the fact that the PM is essentially not involved in maintaining the stability of adjacent segments. This study revealed no significant differences in the CSA or CSA-VI of the MF, ES, or paraspinal muscle groups between the ASDis revision group and the nonrevision group. However, the FCSA, FCSA-VI, and FCSA/CSA ratios of the MF, ES, and paraspinal muscle groups in the ASDis revision group were lower than those in the nonrevision group, indicating that fat tissue without contractile function has replaced contractile muscle fibers. Previous studies have shown a significant negative correlation between the fat fraction of paraspinal muscles and muscle strength [21]. The FCSA/CSA ratio reflects the degree of muscle fat infiltration; a lower FCSA/CSA ratio indicates a greater degree of fat infiltration and weaker muscle strength. The lumbar MF originates from the spinous processes and laminae of the L1 to L5 vertebrae, with its distal attachment to the mammillary processes of the lumbosacral vertebrae and the sacrum, and is adjacent to the ES laterally, which can be divided into superficial and deep layers. The MF is involved in maintaining normal lumbar lordosis and segmental movement [22]. The ES is located lateral to the MF and originates from the dorsal surface of the sacrum, lumbar spinous processes, iliac crest, and lumbodorsal fascia [12]. The ES participates in spinal extension and, together with the MF, counteracts the flexion effect produced by the abdominal muscles during trunk rotation. As the main lumbar extensor muscles, the MF and ES jointly maintain lumbar segmental stability. Therefore, preoperative deterioration of MF and ES quality is associated with postlumbar fusion ASDI revision. Most previous studies on paraspinal muscles have focused on the L3 and L4 levels. Therefore, this study analyzed paraspinal muscle quality at the L3 and L4 levels separately and compared the two. The predictive efficacy of paraspinal muscle quality at the L4 level for postlumbar fusion ASDis revision was greater. This may be because L4 belongs to the lower lumbar spine, where the paraspinal muscles are subjected to greater biomechanical changes and trunk loads. Biomechanical studies on adjacent nonfused segments after PLIF have shown that during lumbar flexion–extension, lateral flexion, and rotation, the pressure on the nucleus pulposus and annulus fibrosus of adjacent nonfused segments after PLIF increases, with the most significant increase occurring during extension. The range of motion (ROM) of adjacent nonfused segments also increases in all directions, especially during flexion and extension. With the progression of ASDis, the intradiscal pressure of adjacent segments increases, whereas the ROM of adjacent segments gradually decreases [23]. Therefore, lumbar flexion-extension movements, especially extension movements, are more closely related to the progression of ASDis. The MF and ES are the main lumbar extensor muscles involved in lumbar extension movement. Studies have shown that deterioration of ES and MF quality is associated with other adjacent segment pathological changes, such as proximal junctional kyphosis and recurrent adjacent segment fractures after surgery [24]. Together with the results of this study, these findings indicate that the MF and ES can reduce the mechanical stress on adjacent nonfused segments and protect adjacent surgical segments. Studies using biomechanical models to explore the impact of paraspinal muscle injury on adjacent segments after lumbar fusion have revealed that the axial compression force and shear force of adjacent segments increase after injury to the paraspinal muscle group, suggesting that the paraspinal muscle group plays an important role in the occurrence and development of ASDis [25]. Consistent with the results of this study, the paraspinal muscle group, as the sum of the ES and MF, plays a major role in lumbar flexion–extension movement and is attached to each lumbar segment. It can counteract the increased intradiscal pressure of adjacent segments, stabilize adjacent segments, and reduce the ROM of adjacent segments. Therefore, compared with ES or MF alone, the FCSA/CSA ratio of the paraspinal muscle group is the most effective predictor of ASDis. Human skeletal muscle fibers are mainly divided into two types: Type I (slow-twitch oxidative fibers) and Type II (fast-twitch fibers). Type II fibers are further divided into Type IIa and Type IIx fibers. Type I fibers have a slow contraction speed but are resistant to fatigue, whereas type II fibers have a fast contraction speed but are more prone to fatigue [22]. According to research, the proportion of different muscle fiber types in the paraspinal muscle group is 60% for Type I, 23% for Type IIa, and 15% for Type IIx [26]. Transformation can occur between Type I and Type II fibers: Type I fibers transform into Type II fibers when muscle use decreases, and Type II fibers transform into Type I fibers when muscle use increases. Studies have shown that in patients with chronic low back pain, the proportion of type I fibers in the MF and ES decreases, the proportion of type II fibers increases, and the number of both types decreases [27-29]. This explains why the FCSA, FCSA-VI, and FCSA/CSA ratios of the MF and ES in the revision group were significantly lower than those in the nonrevision group in this study. A study that performed a biopsy of the MF revealed that the MF contains more fibroadipogenic progenitor cells than the hamstring muscles do, making it more prone to intramuscular fat infiltration and subsequent deterioration of MF quality [30]. These findings indicate that the MF is susceptible to fat infiltration. In this study, the area under the curve (AUC) of the FCSA/CSA ratio of the MF was greater than that of the ES. Moreover, since the MF and ES jointly participate in maintaining adjacent segment stability, the FCSA/CSA ratio of the paraspinal muscle group is an independent predictive factor for the occurrence of postlumbar fusion ASDis revision. Previous studies [15] have shown that deterioration of paraspinal muscle group quality is associated with adjacent segment pathological changes after lumbar fusion. However, these studies did not distinguish between adjacent segment degeneration (ASDeg), with only imaging changes, and ASDis, which require surgical revision. Compared with ASDeg, ASDis requiring surgical revision have a greater impact on patients' postoperative quality of life. Therefore, this study analyzed the paraspinal muscle quality of patients with ASDis who underwent surgical revision. Previous studies [31, 32] analyzing the relationship between paraspinal muscle quality and ASDs did not consider the impact of metabolic diseases such as diabetes mellitus and thyroid dysfunction on paraspinal muscles, nor did they consider whether the control group included patients with ASDis who did not undergo surgery. In contrast, the control group included in this study was evaluated by spinal surgeons as not having ASDI surgical indications; thus, cases where ASDI revision was not performed due to personal willingness and other reasons were excluded. Some studies [33, 34] measured paraspinal muscles at the intervertebral disc level and used the ratio of paraspinal muscle CSA to intervertebral disc CSA to control for the influence of body size. However, this method is easily affected by intervertebral disc bulging and herniation. Therefore, this study performed measurements at the lower endplate level and used the FCSA and CSA normalized to the cross-sectional area of the corresponding vertebral body to calculate the FCSA-VI and CSA-VI to control for body size effects. The results of this study suggest that incorporating the evaluation of preoperative paraspinal muscles, especially the paraspinal muscle group (sum of MF and ES), into routine preoperative evaluation helps to assess the recovery of lumbar function and the risk of reoperation in patients after lumbar fusion. Patients with poor paraspinal muscle group quality on preoperative MRI before lumbar fusion may be more likely to develop ASDis requiring secondary surgical revision in the future, and appropriate strengthening of rehabilitation treatment should be considered. In addition, regarding surgical approach selection, minimally invasive surgical methods that cause less damage to paraspinal muscles, such as minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under a tubular retractor, should be prioritized over traditional open posterior approaches that require extensive dissection of paraspinal muscles. This study revealed that lumbar facet joint degenerative changes are associated with ASDis revision and are an independent predictive factor for ASDis revision. Previous studies have confirmed that lumbar facet joint degenerative changes are associated with ASDeg, with only imaging changes [34]. This may be because the pressure on the facet joints of adjacent segments increases after lumbar fusion, and preoperative facet joint degenerative changes reduce their ability to resist pressure. The limitations of this study include the following: (1) This was a single‑center retrospective study with a relatively small sample size, which may introduce potential bias and limit the generalizability of the results. Therefore, further validation in multicenter, large‑sample, and prospective studies is warranted. (2) The use of the VBQ and HU values to reflect BMD may introduce potential measurement errors. Conclusion This study revealed that deterioration of the quality of the ES, MF, and PSM is associated with postlumbar fusion ASDI revision. The FCSA/CSA ratio of the paraspinal muscle group at the L4 level and the degree of preoperative adjacent segment facet joint degeneration are independent predictive factors for postlumbar fusion ASDis revision. The incorporation of paraspinal muscle quality into routine preoperative evaluations helps predict the risk of reoperation in patients, and strengthening paraspinal muscle exercise may reduce the incidence of ASDis revision. Declarations Funding This study received no direct funding from any third-party donor or funding institution in the public, commercial, or non-profit sectors. Ethical approval and informed consent Ethics Committee of our hospital approved this study, and the need for informed consent requirement was waived owing to the retrospective nature of the study. Competing interest The authors declare no conflicts of interest. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Author Contribution D.D. Li and P. Gao wrote the main manuscript text. Y.J. Chang provided guidance on statistical analysis. X. Tang was responsible for manuscript proofreading. All authors reviewed the manuscript. References Hu MH, Tseng YK, Chung YH, Wu NY, Li CH, Lee PY. The efficacy of oral vitamin D supplements on fusion outcome in patients receiving elective lumbar spinal fusion–a randomized control trial. 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Psoas muscle architectural design, in vivo sarcomere length range, and passive tensile properties support its role as a lumbar spine stabilizer. Spine (Phila Pa 1976). 2011;36(26):E1666–74. Schlaeger S, Inhuber S, Rohrmeier A, Dieckmeyer M, Freitag F, Klupp E, Weidlich D, Feuerriegel G, Kreuzpointner F, Schwirtz A, Rummeny EJ, Zimmer C, Kirschke JS, Karampinos DC, Baum T. Association of paraspinal muscle water-fat MRI-based measurements with isometric strength measurements. Eur Radiol. 2019;29(2):599–608. Noonan AM, Brown SHM. Paraspinal muscle pathophysiology associated with low back pain and spine degenerative disorders. JOR Spine. 2021;4(3):e1171. Jiang S, Li W. Biomechanical study of proximal adjacent segment degeneration after posterior lumbar interbody fusion and fixation: a finite element analysis. J Orthop Surg Res. 2019;14(1):135. Zhang TT, Ding JZ, Kong C, Zhu WG, Wang SK, Lu SB. Paraspinal muscle degeneration and lower bone mineral density as predictors of proximal junctional kyphosis in elderly patients with degenerative spinal diseases: a propensity score matched case–control analysis. BMC Musculoskelet Disord. 2022;23(1):1010. Malakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T. Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J. 2016;25(9):2929–37. Agten A, Stevens S, Verbrugghe J, Eijnde BO, Timmermans A, Vandenabeele F. The lumbar multifidus is characterized by larger type I muscle fibers compared to the erector spinae. Anat Cell Biol. 2020;53(2):143–50. Mannion AF, Käser L, Weber E, Rhyner A, Dvorak J, Müntener M. Influence of age and duration of symptoms on fiber type distribution and size of the back muscles in chronic low back pain patients. Eur Spine J. 2000;9(4):273–81. Mazis N, Papachristou DJ, Zouboulis P, Tyllianakis M, Scopa CD, Megas P. The effect of different physical activity levels on muscle fiber size and type distribution of lumbar multifidus. A biopsy study on low back pain patient groups and healthy control subjects. Eur J Phys Rehabil Med. 2009;45(4):459–67. Agten A, Stevens S, Verbrugghe J, Timmermans A, Vandenabeele F. Biopsy samples from the erector spinae of persons with nonspecific chronic low back pain display a decrease in glycolytic muscle fibers. Spine J. 2020;20(2):199–206. Agha O, Mueller-Immergluck A, Liu M, Zhang H, Theologis AA, Clark A, Kim HT, Liu X, Feeley BT, Bailey JF. Intervertebral disc herniation effects on multifidus muscle composition and resident stem cell populations. JOR Spine. 2020;3(2):e1091. Yun YI, Jeon I, Kim SW, Yu D. Risk factors for adjacent segment disease requiring reoperation after posterior lumbar interbody fusion with screw fixation: focus on paraspinal muscle, facet joint, and disc degeneration. Acta Neurochir (Wien). 2022;164(3):913–22. Chang MY, Park Y, Ha JW, Zhang HY, Lee SH, Hong TH, Lee SH. Paraspinal Lean Muscle Mass Measurement Using Spine MRI as a Predictor of Adjacent Segment Disease After Lumbar Fusion: A Propensity Score-Matched Case–Control Analysis. AJR Am J Roentgenol. 2019;212(6):1310–7. Gong Z, Li D, Zou F, Liu S, Wang H, Ma X. Low lumbar multifidus muscle status and bone mineral density are important risk factors for adjacent segment disease after lumbar fusion: a case–control study. J Orthop Surg Res. 2022;17(1):490. Kim JY, Ryu DS, Paik HK, Ahn SS, Kang MS, Kim KH, Park JY, Chin DK, Kim KS, Cho YE, Kuh SU. Paraspinal muscle, facet joint, and disc problems: risk factors for adjacent segment degeneration after lumbar fusion. Spine J. 2016;16(7):867–75. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 14 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviews received at journal 06 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 30 Mar, 2026 Editor assigned by journal 25 Mar, 2026 Submission checks completed at journal 25 Mar, 2026 First submitted to journal 17 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9149969","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":615197488,"identity":"bff461fd-1569-40ea-99e5-a6c1660a203b","order_by":0,"name":"Dandan li","email":"","orcid":"","institution":"Department of Radiology, Xijing Hospital, Fourth Military Medical Universit","correspondingAuthor":false,"prefix":"","firstName":"Dandan","middleName":"","lastName":"li","suffix":""},{"id":615197489,"identity":"dfb7eb18-3bc4-47ba-af1d-8c2f1949224b","order_by":1,"name":"Peng Gao","email":"","orcid":"","institution":"Department of radiology, XD Group Hospital","correspondingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Gao","suffix":""},{"id":615197490,"identity":"355abd0f-7e1e-4745-9c93-71d6ecdc0734","order_by":2,"name":"Yingjuan Chang","email":"","orcid":"","institution":"Department of Radiology, Xijing Hospital, Fourth Military Medical Universit","correspondingAuthor":false,"prefix":"","firstName":"Yingjuan","middleName":"","lastName":"Chang","suffix":""},{"id":615197491,"identity":"a5a01a2f-a2fb-459d-9c21-059787619239","order_by":3,"name":"Xing Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYNACAwYGNvbmAwYfDGzsCCrmgWnh4zmWUDijIC2ZSC1AICeRY/CZ58MhxgZCWuzZzx5+zVNwx65NIi1xs43BAWYG9sNHN+C1hScvzXKGwbPkNp7Hh41zDO7wMfCkpd3A77AcM6CvDyezsaelAbU8Y2aQ4DHDr4X/jZlBAkgLQ475bwuDw4wNBLVI5Bg/ANpix8aRY2DMQJSWG2/MGGcYHE5gAwayYY9BWjIbIb+w9+cYf+b5c9hevh0YlT/+2Njxsx8+hlcLELBJAInEBjiXgHIQYP4AJOyJUDgKRsEoGAUjFQAABWJJnQPihLgAAAAASUVORK5CYII=","orcid":"","institution":"Department of Radiology, Xijing Hospital, Fourth Military Medical Universit","correspondingAuthor":true,"prefix":"","firstName":"Xing","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2026-03-17 14:25:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9149969/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9149969/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105984405,"identity":"e37684c1-71ac-4615-b5c8-ae8d9abd26c2","added_by":"auto","created_at":"2026-04-02 07:14:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":321181,"visible":true,"origin":"","legend":"\u003cp\u003eCSA (yellow outlined area) and FCSA (red filled area) of the psoas major muscle, erector spinae muscle, multifidus muscle, and paraspinal muscle groups\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9149969/v1/c8cd7ff594328385d34d69c3.png"},{"id":105984404,"identity":"b4d2236a-ddcc-4c30-9b30-9ec326bda77a","added_by":"auto","created_at":"2026-04-02 07:14:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":117594,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic VBQ score measurement\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9149969/v1/b2b77ec8d382edb47ede405d.png"},{"id":106093563,"identity":"39e9a9a1-ab2a-4252-bff3-4199f5dc3162","added_by":"auto","created_at":"2026-04-03 11:38:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1196581,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9149969/v1/21d94dd7-3c4b-4f24-8a7a-f15a418dd26a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Paraspinal Muscle Quality and Adjacent Facet Joint Degeneration as Significant Predictors of ASDis Revision After Lumbar Fusion","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbar fusion is currently the main treatment for various lumbar pathologies, including degenerative lumbar instability, degenerative disc disease, severe spondylolisthesis, lumbar spinal stenosis, and lumbar deformity[1,2]. Lumbar fusion can be classified into posterior, anterior, and transforaminal lumbar interbody fusion. Among these approaches, posterior lumbar interbody fusion (PLIF) with pedicle screw fixation is widely utilized clinically because of its high safety profile and convenient operability[3,4]. While often a successful procedure, lumbar fusion is not without complications. One known complication is adjacent segment disease (ASDis)[5]. It is thought that abnormal mechanical loading and increased motion through proximal or distal segments can accelerate degenerative changes in unfused segments[6,7,8]. The development of ASD significantly impairs the quality of life of patients following lumbar fusion surgery, and in severe cases, it necessitates revision surgery on adjacent segments. Therefore, identifying the risk factors for ASDis during revision surgery is highly important.\u003c/p\u003e\n\u003cp\u003eParaspinal muscle quality deterioration is characterized primarily by paraspinal muscle atrophy, which is specifically characterized by reduced paraspinal muscle mass and increased fat infiltration. Currently, the clinical utility of imaging-based evaluation of paraspinal muscle quality deterioration as a prognostic marker has been increasingly validated across multiple surgical subspecialties, including metastatic diseases, trauma, and fractures[9,10,11,12]. Despite extensive research focused on identifying potential determinants of revision surgery, the association between paraspinal muscle quality and revision surgery remains inadequately understood. Therefore, by comparing paraspinal muscle quality based on preoperative imaging data between patients who underwent revision surgery and those who did not undergo revision surgery due to the absence of clinical surgical indications, this study aimed to explore the relationships between changes in paraspinal muscle quality and revision after lumbar fusion, as well as to analyze other imaging risk factors for revision surgery.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003ePatient selection\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by the Ethics Committee of The First Affiliated Hospital of Dalian Medical University, and this research was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. This study retrospectively reviewed the medical records and imaging data of all patients who underwent PLIF with screw fixation for degenerative spinal diseases between January 2007 and January 2023. The inclusion criterion was a preoperative diagnosis of degenerative lumbar diseases, including spinal stenosis, degenerative lumbar spondylolisthesis, and lumbar disc herniation. The exclusion criteria were as follows: (1) history of other nondegenerative diseases affecting the spinal structure, such as spinal tumors, spinal infections, and spinal fractures; (2) previous history of paraspinal muscle injury or infection; (3) comorbidities of metabolic diseases that may affect paraspinal muscle metabolism, including diabetes mellitus, thyroid dysfunction, and hyperuricemia; and (4) incomplete lumbar imaging data. During the study period, 957 patients underwent PLIF with screw fixation, among whom 41 patients who met the aforementioned exclusion criteria were excluded. Ultimately, 916 patients were included in the retrospective analysis, 41 of whom underwent secondary revision surgery and were assigned to the revision surgery group. Surgical indications for ASD revision: Severe clinical symptoms (low back pain, radicular pain or numbness, intermittent claudication, etc.) that significantly impair patients' daily living activities and fail to respond to 3 months of conservative treatment. To identify factors associated with revision surgery, 41 patients who underwent single PLIF with pedicle screw fixation were selected as the control group via propensity score matching (PSM). These patients were matched to the revision surgery group for age, sex, body mass index (BMI), number of fused segments, and follow-up duration.\u003c/p\u003e\n\u003cp\u003eMRI equipment and scanning parameters\u003c/p\u003e\n\u003cp\u003eA GE 3.0T Signa HDxt scanner was used, with a spinal coil for image acquisition. The scanning sequences included sagittal T1-weighted (T1W), sagittal T2-weighted (T2W), sagittal T2W fat suppression, and axial T2W. Axial T2W images were analyzed, with a repetition time/echo time (TR/TE) of 2900–4880 ms/102–120 ms, a field of view (FOV) of 18×18–22×22 cm, a slice thickness of 4.0 mm, and a 320×256 matrix. For the sagittal T1W images, the TR/TE was 300–900 ms/7–15 ms, the FOV was 32×32 cm, the slice thickness was 4.0 mm, and the matrix width was 320×224.\u003c/p\u003e\n\u003cp\u003eCT and X-ray equipment and parameters\u003c/p\u003e\n\u003cp\u003eLumbar CT images were obtained via a SIEMENS Emotion 16-slice spiral CT scanner or a GE Light speed 16-slice spiral CT scanner with a tube voltage of 120 kV, a tube current of 240–320 mAs, a slice thickness of 1 mm, a slice spacing of 1 mm, a rotation speed of 0.6–0.7 s, a pitch of 0.9–1.5 mm, and a matrix of 380×380. Lumbar lateral X-ray images were taken via SIEMENS Aristos MX or SIEMENS Aristos VX digital X-ray equipment, with a tube voltage of 81 kV and a tube current of 40 mAs.\u003c/p\u003e\n\u003cp\u003e4. Data Measurement\u003c/p\u003e\n\u003cp\u003e4.1 Measurement of Paraspinal Muscles\u003c/p\u003e\n\u003cp\u003ePreoperative lumbar axial T2WI images were exported in DICOM format, and ImageJ software (version 1.53u, National Institutes of Health, USA) was used to analyze the images at the level of the lower endplates of the 3rd and 4th lumbar vertebrae. These two levels were selected because the maximum cross-sectional area of the psoas major muscle is located at the L4/5 level, the maximum cross-sectional areas of the multifidus muscle and erector spinae muscle are between the L3/4 and L4/5 levels [13], and the optimal level was selected by comparison. Two radiologists with more than 2 years of work experience who were familiar with paraspinal muscle anatomy delineated the region of interest (ROI) and measured the paraspinal muscle data in a double-blind manner. The methods for ROI delineation and data measurement of paraspinal muscles were as follows: ImageJ software was used to delineate the psoas major muscle (PM), erector spinae muscle (RS), and multifidus muscle (MF) along their edges to obtain the total CSA of the PM, ES, MF, and PSM (i.e., the sum of the erector spinae muscle and multifidus muscle) (as shown in Figure 1). Threshold extraction technology was used to obtain the pure muscle area without fat of each paraspinal muscle, namely, the functional cross-sectional area (FCSA) (as shown in Figure 1). Meanwhile, the vertebral cross-sectional area (VCSA) at the corresponding level was measured. To eliminate the influence of body size on the paraspinal muscle area, the muscle-vertebra index was used to standardize the CSA and FCSA, the total cross-sectional area-vertebra index (CSA-VI) and functional cross-sectional area-vertebra index (FCSA-VI) (CSA-VI=100×CSA/VCSA, FCSA-VI= 100×FCSA/VCSA) were obtained, and the FCSA/CSA ratio was calculated. The specific method of threshold extraction technology was as follows: to avoid adipose tissue within the CSA of paraspinal muscles, 4--6 ROIs containing only muscle tissue were selected, the maximum gray value measured among them was taken as the maximum threshold for distinguishing muscle tissue from adipose tissue, and the minimum threshold was set to 0. The area within this threshold range was the FCSA [14].\u003c/p\u003e\n\u003cp\u003e4.2 Other Measurement Indicators\u003c/p\u003e\n\u003cp\u003e(1) Facet joint degeneration: The degree of facet joint degeneration in adjacent segments was graded via the Weishaupt classification system on the basis of lumbar CT images. Two radiologists with more than 2 years of work experience performed the grading, and inconsistent cases were determined by joint consultation. The specific Weishaupt classification was as follows: Grade 0: normal facet joint space (2–4 mm in width); Grade 1: narrowed facet joint space (\u0026lt;2 mm) and/or small osteophyte formation and/or mild hypertrophy of the articular processes; Grade 2: narrowed facet joint space and/or moderate osteophyte formation and/or moderate hypertrophy of the articular processes and/or mild subchondral bone destruction; Grade 3: narrowed facet joint space and/or large osteophyte formation and/or severe hypertrophy of the articular processes and/or severe subchondral bone destruction or cystic changes [15].\u003c/p\u003e\n\u003cp\u003e(2) MRI-based vertebral bone quality (VBQ) score: the ratio of the average signal intensity of the 1st to 4th lumbar vertebrae on the mid-sagittal T1WI to the cerebrospinal fluid signal intensity at the level of the 3rd lumbar vertebra, which can reflect vertebral bone quality and assess vertebral osteoporosis [16]. The specific ROI delineation is shown in Figure 2. During measurement, if the mid-sagittal plane is covered by mixed signals such as the venous plexus, the left or right parasagittal plane is used; if there are still mixed signals in the parasagittal plane, the vertebra is discarded; if the cerebrospinal fluid signal at the level of the 3rd lumbar vertebra is covered due to stenosis or other reasons, the cerebrospinal fluid signal at the level of the 2nd or 4th lumbar vertebra is used. Two radiologists with more than 2 years of work experience performed the measurements independently in a double-blinded manner.\u003c/p\u003e\n\u003cp\u003e(3) CT-based vertebral Hounsfield unit (HU) value: The 1st lumbar vertebra was selected as the target vertebra in this study because it is the first vertebra not connected to the ribs, is easy to identify, and is less prone to degeneration than other vertebrae are. ROIs were delineated at the middle level of the 1st lumbar vertebra, the first level below the upper endplate, and the first level above the lower endplate. During delineation, structures such as the cortical bone and venous plexus were avoided, and the average HU value of the three levels was finally calculated [17]. Two radiologists with more than 2 years of work experience performed the measurements independently in a double-blinded manner.\u003c/p\u003e\n\u003cp\u003eLumbar lordosis (LL): The angle between the upper endplate of the 1st lumbar vertebra and the upper endplate of the sacral vertebra, reflecting sagittal spinal balance. Preoperative LL and postoperative LL were measured on preoperative and postoperative lumbar X-ray images of patients, respectively. Two radiologists with more than 2 years of work experience performed the measurements independently in a double-blinded manner. Statistical analysis.\u003c/p\u003e\n\u003cp\u003eFor statistical analysis and model development, SPSS 27.0 and MedCalc software (version 20.022) were used. Interobserver consistency for all the quantitative measurements was evaluated via the intraclass correlation coefficient (ICC). Categorical variables, including sex and the number of fused segments, were analyzed with Pearson’s chi-square test. Normality testing was conducted for all continuous variables prior to subsequent analyses. Continuous variables that conformed to a normal distribution are expressed as the means ± standard deviations and were compared via the independent samples t test, whereas those that did not meet the normality assumption were analyzed via nonparametric tests. For paraspinal muscle parameters with statistically significant differences between groups, receiver operating characteristic (ROC) curves were constructed to calculate the area under the curve (AUC), and the optimal cutoff values, sensitivity, and specificity were determined. The Delong test was applied to compare AUC values among different parameters. Univariate analyses, including Pearson’s chi-square test and the independent samples t test as appropriate, were performed to assess the differences in facet joint degeneration grades, VBQ values, HU values, preoperative LL values, and postoperative LL values between the experimental group and the control group. Logistic regression analysis was then conducted incorporating paraspinal muscle parameters and positive results from the univariate analysis to identify independent predictors of ASD revision. A \u003cem\u003eP\u003c/em\u003e value of \u0026lt;0.05 was considered to indicate statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eComparison of basic patient data\u003c/p\u003e\n\u003cp\u003eA total of 82 patients were retrospectively analyzed in this single-center study. The patients were divided into two groups: the revision group (41 patients) and the control group (41 patients). Table 1 summarizes the basic data of these groups, including age, sex, height, weight, BMI, number of fused segments\u0026nbsp;and follow-up duration. No significant differences were detected between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003eTable 1 Baseline characteristics of the study population revision and control groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 22px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003eDifferent groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eRevision group（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eControl group（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eAge (yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e64.83\u0026plusmn;9.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e63.54\u0026plusmn;9.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.537\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eHeight（cm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e168.83\u0026plusmn;8.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e166.73\u0026plusmn;5.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.338\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eWeight（kg）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e73.96\u0026plusmn;10.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e71.55\u0026plusmn;11.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e25.88\u0026plusmn;2.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e25.70\u0026plusmn;3.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.806\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eNumber of fused segments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eFollow-up duration（mth）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e53（24，93）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e55（30，92）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.700\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eRadiological characteristics\u003c/p\u003e\n\u003cp\u003eComparisons of the quantitative parameters of the paraspinal muscles between the revision group and the control group in patients who underwent lumbar fusion at the L3 and L4 levels are shown in Tables 2 and 3, respectively. At the L3 and L4 levels, there were no statistically significant differences in the CSA, CSA-VI, FCSA, FCSA-VI, or FCSA/CSA ratio of the psoas major muscle between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05). No statistically significant differences were detected in the CSA or CSA-VI of the paravertebral muscle group, erector spinae muscles, or multifidus muscles between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05). The FCSA, FCSA-VI, and FCSA/CSA ratios of the paravertebral muscle group in the revision group were significantly lower than those in the control group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). The FCSA, FCSA-VI, and FCSA/CSA ratios of the erector spinae muscles in the revision group were significantly lower than those in the control group (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). The FCSA, FCSA-VI, and FCSA/CSA ratios of the multifidus muscles in the revision group were significantly lower than those in the control group.\u003c/p\u003e\n\u003cp\u003eTable 2 Comparison of paraspinal muscle parameters at the L3 level between patients who underwent ASDis revision surgery and those who did not undergo revision surgery after lumbar fusion\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003erevision group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;control group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eL3 CSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e1704.85\u0026plusmn;650.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1701.83\u0026plusmn;590.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e4857.16\u0026plusmn;1013.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e4573.16\u0026plusmn;935.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e1.319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.191\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e3578.01\u0026plusmn;880.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e3348.07\u0026plusmn;750.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.960\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.337\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e1279.58\u0026plusmn;260.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1225.09\u0026plusmn;292.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eL3 FCSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e1510.85\u0026plusmn;620.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1519.84\u0026plusmn;606.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e2599.51\u0026plusmn;1034.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e3346.14\u0026plusmn;790.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-3.672\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e2063.46\u0026plusmn;821.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2546.30\u0026plusmn;610.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-3.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e531.37\u0026plusmn;267.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e802.28\u0026plusmn;248.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-4.750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eL3 CSA-VI(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e101.88\u0026plusmn;33.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e107.79\u0026plusmn;33.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.430\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e295.61\u0026plusmn;59.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e293.25\u0026plusmn;65.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.849\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e217.71\u0026plusmn;51.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e214.79\u0026plusmn;53.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e77.92\u0026plusmn;15.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e78.46\u0026plusmn;19.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eL3 FCSA-VI(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e90.23\u0026plusmn;32.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e95.97\u0026plusmn;34.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.778\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.439\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e157.87\u0026plusmn;58.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e215.72\u0026plusmn;59.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-4.478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e124.49\u0026plusmn;45.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e164.18\u0026plusmn;46.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-3.898\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e32.18\u0026plusmn;15.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e51.68\u0026plusmn;16.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-5.470\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eL3 FCSA/CSA\u0026nbsp;ratio(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e87.68\u0026plusmn;6.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e88.17\u0026plusmn;7.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e52.64\u0026plusmn;15.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e73.75\u0026plusmn;13.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-6.472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e56.85\u0026plusmn;15.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e76.67\u0026plusmn;12.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-6.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e40.98\u0026plusmn;17.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e66.09\u0026plusmn;17.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-6.535\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3 Comparison of paraspinal muscle parameters at the L4 level between patients who underwent ASDis revision surgery and those who did not undergo revision surgery after lumbar fusion\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003erevision group（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003econtrol group\u0026nbsp;（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eL4 CSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e2244.22\u0026plusmn;788.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2143.49\u0026plusmn;649.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.631\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.530\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e4641.20\u0026plusmn;744.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e4361.25\u0026plusmn;980.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e1.456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e2833.96\u0026plusmn;617.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e2651.01\u0026plusmn;679.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e1.243\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.214\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e1815.40\u0026plusmn;321.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n 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\u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e1704.64\u0026plusmn;461.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1943.95\u0026plusmn;554.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-1.994\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.046\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e687.45\u0026plusmn;355.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1028.14\u0026plusmn;267.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n 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style=\"width: 24px;\"\u003e\n \u003cp\u003e142.72\u0026plusmn;37.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-0.096\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e303.01\u0026plusmn;58.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e297.16\u0026plusmn;76.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n 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FCSA-VI(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e124.57\u0026plusmn;41.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e138.76\u0026plusmn;35.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-1.665\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n 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\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e87.39\u0026plusmn;11.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e97.28\u0026plusmn;1.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-5.285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e49.99\u0026plusmn;8.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e68.22\u0026plusmn;7.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-10.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e59.88\u0026plusmn;7.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e73.30\u0026plusmn;8.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-7.726\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e37.19\u0026plusmn;17.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e60.34\u0026plusmn;9.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e-7.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＜\u003c/strong\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe results of Delong\u0026apos;s test for comparing the area under the curve (AUC) of each quantitative parameter between the L3 and L4 levels are shown in Table 4. The AUC of the FCSA/CSA ratio of the paravertebral muscle group at the L4 level was significantly greater than that at the L3 level (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). The results of the ROC curve analysis for each parameter are presented in Table 5. At the L4 level, the AUC values of the paravertebral muscle group FCSA, erector spinae muscle FCSA, multifidus muscle FCSA, paravertebral muscle group FCSA-VI, erector muscle group FCSA-VI, multifidus muscle FCSA-VI, paravertebral muscle group FCSA/CSA ratio, erector spinae muscle FCSA/CSA ratio, and multifidus muscle FCSA/CSA ratio were 0.761, 0.621, 0.781, 0.773, 0.651, 0.836, 0.942, 0.881, and 0.869, respectively. Delong\u0026apos;s test revealed that the AUC of the paravertebral muscle group FCSA/CSA ratio was significantly greater than that of the other paraspinal muscle parameters (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05). Therefore, the FCSA/CSA ratio of the paravertebral muscle group at the L4 level was identified as a potential predictor for the revision of ASDis after lumbar fusion.\u003c/p\u003e\n\u003cp\u003eTable 4 Comparison of the AUCs of paraspinal muscle parameters at the L3 and L4 levels\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"96%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003eAUC(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eL3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eL4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eFCSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.730(0.621-0.822)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.761(0.654- 0.848)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.546\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.707(0.596-0.803)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.621(0.514-0.732)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.786(0.682- 0.869)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.781(0.676- 0.865)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.922\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eFCSA-VI(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.755(0.647-0.843)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.773(0.667-0.858)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.792\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.735(0.626- 0.826)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.651(0.538- 0.753)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.248\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.810(0.709 -0.888)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.836 (0.738-0.909)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.668\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eFCSA/CSA\u0026nbsp;ratio (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.846(0.749-0.916)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.942(0.867-0.981)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.843(0.746-0.914)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.881(0.791-0.942)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.844(0.747-0.915)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e0.869(0.776-0.933)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5 ROC curve analysis of paraspinal muscle parameters at the L4 level\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eAUC(95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eCut off\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eSensitivity（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eSpecificity（%）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eL4 FCSA(mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.761(0.654- 0.848)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.054\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e2383.194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e68.29%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e90.24%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.621(0.514-0.732)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1574..353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e53.66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e70.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.781(0.737- 0.908)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e842.711\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e73.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e82.93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eL4 FCSA-VI(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.773(0.667-0.858)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e154.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e63.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e82.93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.651(0.538- 0.753)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e117.218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e63.41%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e65.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.836 (0.738-0.909)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e49.604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e70.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e90.24%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eL4 FCSA/CSA\u0026nbsp;ratio (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003ePVM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.942(0.867-0.981)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e56.612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e85.37%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e92.68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.881(0.791-0.942)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e63.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e75.61%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e87.80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eMF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.869(0.776-0.933)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e50.512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e78.05%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e92.68%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe results of the univariate analysis of preoperative adjacent segment facet joint degeneration grade, preoperative LL, postoperative LL, the VBQ score, and the vertebral body HU value between the revision group and the nonrevision group are shown in Table 6. Among these indicators, no statistically significant differences were observed in preoperative LL, postoperative LL, the VBQ score, or the HU value between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026gt;0.05). The grade of preoperative adjacent segment facet joint degeneration in the revision group was significantly greater than that in the control group (\u003cem\u003eP\u003c/em\u003e \u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eTable 6 Univariate analysis of other measured indicators between the revision group and the\u0026nbsp;control\u0026nbsp;group\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003erevision group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003econtrol group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eFacet joint degeneration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003ePreoperative LL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e31.029\u0026plusmn;8.777\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e30.234\u0026plusmn;9.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.688\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003ePostoperative LL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e34.650\u0026plusmn;8.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e33.761\u0026plusmn;8.430\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eVBQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e3.228\u0026plusmn;0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e3.531\u0026plusmn;0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eHU value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e127.340\u0026plusmn;30.929\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e130.926\u0026plusmn;36.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e0.630\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eLogistic regression analysis of risk factors for revision surgery for ASDis\u003c/p\u003e\n\u003cp\u003eOn the basis of the results of univariate analysis and ROC curve analysis, the paraspinal muscle FCSA/CSA ratio and preoperative degenerative grading of facet joints at adjacent segments were included in the logistic regression analysis. The results are presented in Table 7. According to the logistic regression model, the paraspinal muscle FCSA/CSA ratio (OR 0.731; 95% CI 0.633\u0026ndash;0.844; \u003cem\u003eP\u003c/em\u003e\u0026lt;0.001) and preoperative degenerative grade of adjacent segment facet joints (OR 4.664; 95% CI 1.235\u0026ndash;17.617; \u003cem\u003eP\u003c/em\u003e=0.023) were identified as independent predictors for the occurrence of ASDis revision surgery.\u003c/p\u003e\n\u003cp\u003eTable 7 Logistic regression analysis of risk factors for ASDis revision surgery\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003eWald value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eL4 PVM FCSA/CSA ratio\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e-0.313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e18.367\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.633-0.844\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eFacet joint degeneration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1.540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e5.157\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e4.664\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.235-17.617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eInterobserver reliability\u003c/p\u003e\n\u003cp\u003eThe consistency of the measurements of paraspinal muscle parameters, VBQ scores, vertebral body HU values, preoperative LL, and postoperative LL by the two observers was good (ICC: 0.820\u0026ndash;0.992).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eParaspinal muscles are key contributors to spinal stability. In recent years, studies investigating the relationship between decreased paraspinal muscle quality and adverse outcomes after lumbar surgery have reported that preoperative paraspinal muscle atrophy and increased fat infiltration can predict postoperative dysfunction, low back pain, and various complications and may also be associated with the risk of revision lumbar surgery[18]. ASDis is a common complication following lumbar fusion that impairs patients' quality of life and may require revision surgery in severe cases.\u003c/p\u003e\n\u003cp\u003eThis study controlled for the influence of confounding factors such as age, sex, BMI, number of fused segments, and follow-up duration via propensity score matching. On the basis of preoperative MR images, we analyzed the relationships between the quality of the PM, ES, MF, and PSM and ASDis after PLIF with pedicle screw fixation. We found no significant differences in the preoperative PM CSA, FCSA, CSA-VI, FCSA-VI, or FCSA/CSA ratio between the revision group and the control group.\u003c/p\u003e\n\u003cp\u003eThe PM is the main muscle of the anterior group of lumbar paraspinal muscles, originating from and spanning multiple lumbar vertebral segments [12]. The bilateral PM muscles participate in lumbar lateral flexion through axial compression and coordinated interactions but play a minor role in maintaining lumbar segmental stability. In addition, the PM is involved in hip joint movement [19, 20]. The lack of association between PM quality deterioration and the occurrence of postlumbar fusion ASDis may be attributed to the fact that the PM is essentially not involved in maintaining the stability of adjacent segments.\u003c/p\u003e\n\u003cp\u003eThis study revealed no significant differences in the CSA or CSA-VI of the MF, ES, or paraspinal muscle groups between the ASDis revision group and the nonrevision group. However, the FCSA, FCSA-VI, and FCSA/CSA ratios of the MF, ES, and paraspinal muscle groups in the ASDis revision group were lower than those in the nonrevision group, indicating that fat tissue without contractile function has replaced contractile muscle fibers. Previous studies have shown a significant negative correlation between the fat fraction of paraspinal muscles and muscle strength [21]. The FCSA/CSA ratio reflects the degree of muscle fat infiltration; a lower FCSA/CSA ratio indicates a greater degree of fat infiltration and weaker muscle strength.\u003c/p\u003e\n\u003cp\u003eThe lumbar MF originates from the spinous processes and laminae of the L1 to L5 vertebrae, with its distal attachment to the mammillary processes of the lumbosacral vertebrae and the sacrum, and is adjacent to the ES laterally, which can be divided into superficial and deep layers. The MF is involved in maintaining normal lumbar lordosis and segmental movement [22]. The ES is located lateral to the MF and originates from the dorsal surface of the sacrum, lumbar spinous processes, iliac crest, and lumbodorsal fascia [12]. The ES participates in spinal extension and, together with the MF, counteracts the flexion effect produced by the abdominal muscles during trunk rotation. As the main lumbar extensor muscles, the MF and ES jointly maintain lumbar segmental stability. Therefore, preoperative deterioration of MF and ES quality is associated with postlumbar fusion ASDI revision.\u003c/p\u003e\n\u003cp\u003eMost previous studies on paraspinal muscles have focused on the L3 and L4 levels. Therefore, this study analyzed paraspinal muscle quality at the L3 and L4 levels separately and compared the two. The predictive efficacy of paraspinal muscle quality at the L4 level for postlumbar fusion ASDis revision was greater. This may be because L4 belongs to the lower lumbar spine, where the paraspinal muscles are subjected to greater biomechanical changes and trunk loads.\u003c/p\u003e\n\u003cp\u003eBiomechanical studies on adjacent nonfused segments after PLIF have shown that during lumbar flexion–extension, lateral flexion, and rotation, the pressure on the nucleus pulposus and annulus fibrosus of adjacent nonfused segments after PLIF increases, with the most significant increase occurring during extension. The range of motion (ROM) of adjacent nonfused segments also increases in all directions, especially during flexion and extension. With the progression of ASDis, the intradiscal pressure of adjacent segments increases, whereas the ROM of adjacent segments gradually decreases [23]. Therefore, lumbar flexion-extension movements, especially extension movements, are more closely related to the progression of ASDis.\u003c/p\u003e\n\u003cp\u003eThe MF and ES are the main lumbar extensor muscles involved in lumbar extension movement. Studies have shown that deterioration of ES and MF quality is associated with other adjacent segment pathological changes, such as proximal junctional kyphosis and recurrent adjacent segment fractures after surgery [24]. Together with the results of this study, these findings indicate that the MF and ES can reduce the mechanical stress on adjacent nonfused segments and protect adjacent surgical segments.\u003c/p\u003e\n\u003cp\u003eStudies using biomechanical models to explore the impact of paraspinal muscle injury on adjacent segments after lumbar fusion have revealed that the axial compression force and shear force of adjacent segments increase after injury to the paraspinal muscle group, suggesting that the paraspinal muscle group plays an important role in the occurrence and development of ASDis [25]. Consistent with the results of this study, the paraspinal muscle group, as the sum of the ES and MF, plays a major role in lumbar flexion–extension movement and is attached to each lumbar segment. It can counteract the increased intradiscal pressure of adjacent segments, stabilize adjacent segments, and reduce the ROM of adjacent segments. Therefore, compared with ES or MF alone, the FCSA/CSA ratio of the paraspinal muscle group is the most effective predictor of ASDis.\u003c/p\u003e\n\u003cp\u003eHuman skeletal muscle fibers are mainly divided into two types: Type I (slow-twitch oxidative fibers) and Type II (fast-twitch fibers). Type II fibers are further divided into Type IIa and Type IIx fibers. Type I fibers have a slow contraction speed but are resistant to fatigue, whereas type II fibers have a fast contraction speed but are more prone to fatigue [22]. According to research, the proportion of different muscle fiber types in the paraspinal muscle group is 60% for Type I, 23% for Type IIa, and 15% for Type IIx [26]. Transformation can occur between Type I and Type II fibers: Type I fibers transform into Type II fibers when muscle use decreases, and Type II fibers transform into Type I fibers when muscle use increases.\u003c/p\u003e\n\u003cp\u003eStudies have shown that in patients with chronic low back pain, the proportion of type I fibers in the MF and ES decreases, the proportion of type II fibers increases, and the number of both types decreases [27-29]. This explains why the FCSA, FCSA-VI, and FCSA/CSA ratios of the MF and ES in the revision group were significantly lower than those in the nonrevision group in this study. A study that performed a biopsy of the MF revealed that the MF contains more fibroadipogenic progenitor cells than the hamstring muscles do, making it more prone to intramuscular fat infiltration and subsequent deterioration of MF quality [30]. These findings indicate that the MF is susceptible to fat infiltration.\u003c/p\u003e\n\u003cp\u003eIn this study, the area under the curve (AUC) of the FCSA/CSA ratio of the MF was greater than that of the ES. Moreover, since the MF and ES jointly participate in maintaining adjacent segment stability, the FCSA/CSA ratio of the paraspinal muscle group is an independent predictive factor for the occurrence of postlumbar fusion ASDis revision.\u003c/p\u003e\n\u003cp\u003ePrevious studies [15] have shown that deterioration of paraspinal muscle group quality is associated with adjacent segment pathological changes after lumbar fusion. However, these studies did not distinguish between adjacent segment degeneration (ASDeg), with only imaging changes, and ASDis, which require surgical revision. Compared with ASDeg, ASDis requiring surgical revision have a greater impact on patients' postoperative quality of life. Therefore, this study analyzed the paraspinal muscle quality of patients with ASDis who underwent surgical revision.\u003c/p\u003e\n\u003cp\u003ePrevious studies [31, 32] analyzing the relationship between paraspinal muscle quality and ASDs did not consider the impact of metabolic diseases such as diabetes mellitus and thyroid dysfunction on paraspinal muscles, nor did they consider whether the control group included patients with ASDis who did not undergo surgery. In contrast, the control group included in this study was evaluated by spinal surgeons as not having ASDI surgical indications; thus, cases where ASDI revision was not performed due to personal willingness and other reasons were excluded.\u003c/p\u003e\n\u003cp\u003eSome studies [33, 34] measured paraspinal muscles at the intervertebral disc level and used the ratio of paraspinal muscle CSA to intervertebral disc CSA to control for the influence of body size. However, this method is easily affected by intervertebral disc bulging and herniation. Therefore, this study performed measurements at the lower endplate level and used the FCSA and CSA normalized to the cross-sectional area of the corresponding vertebral body to calculate the FCSA-VI and CSA-VI to control for body size effects.\u003c/p\u003e\n\u003cp\u003eThe results of this study suggest that incorporating the evaluation of preoperative paraspinal muscles, especially the paraspinal muscle group (sum of MF and ES), into routine preoperative evaluation helps to assess the recovery of lumbar function and the risk of reoperation in patients after lumbar fusion. Patients with poor paraspinal muscle group quality on preoperative MRI before lumbar fusion may be more likely to develop ASDis requiring secondary surgical revision in the future, and appropriate strengthening of rehabilitation treatment should be considered.\u003c/p\u003e\n\u003cp\u003eIn addition, regarding surgical approach selection, minimally invasive surgical methods that cause less damage to paraspinal muscles, such as minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under a tubular retractor, should be prioritized over traditional open posterior approaches that require extensive dissection of paraspinal muscles.\u003c/p\u003e\n\u003cp\u003eThis study revealed that lumbar facet joint degenerative changes are associated with ASDis revision and are an independent predictive factor for ASDis revision. Previous studies have confirmed that lumbar facet joint degenerative changes are associated with ASDeg, with only imaging changes [34]. This may be because the pressure on the facet joints of adjacent segments increases after lumbar fusion, and preoperative facet joint degenerative changes reduce their ability to resist pressure.\u003c/p\u003e\n\u003cp\u003eThe limitations of this study include the following: (1) This was a single‑center retrospective study with a relatively small sample size, which may introduce potential bias and limit the generalizability of the results. Therefore, further validation in multicenter, large‑sample, and prospective studies is warranted. (2) The use of the VBQ and HU values to reflect BMD may introduce potential measurement errors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed that deterioration of the quality of the ES, MF, and PSM is associated with postlumbar fusion ASDI revision. The FCSA/CSA ratio of the paraspinal muscle group at the L4 level and the degree of preoperative adjacent segment facet joint degeneration are independent predictive factors for postlumbar fusion ASDis revision. The incorporation of paraspinal muscle quality into routine preoperative evaluations helps predict the risk of reoperation in patients, and strengthening paraspinal muscle exercise may reduce the incidence of ASDis revision.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no direct funding from any third-party donor or funding institution in the public, commercial, or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics Committee of our hospital approved this study, and the need for informed consent requirement was waived owing to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eD.D. Li and P. Gao wrote the main manuscript text. Y.J. Chang provided guidance on statistical analysis. X. Tang was responsible for manuscript proofreading. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHu MH, Tseng YK, Chung YH, Wu NY, Li CH, Lee PY. The efficacy of oral vitamin D supplements on fusion outcome in patients receiving elective lumbar spinal fusion\u0026ndash;a randomized control trial. BMC Musculoskelet Disord. 2022;23(1):996. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12891-022-05948-9\u003c/span\u003e\u003cspan address=\"10.1186/s12891-022-05948-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2022 Nov 18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRathbone J, Rackham M, Nielsen D, Lee SM, Hing W, Riar S, Scott-Young M. 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BMC Musculoskelet Disord. 2022;23(1):1010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T. Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J. 2016;25(9):2929\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgten A, Stevens S, Verbrugghe J, Eijnde BO, Timmermans A, Vandenabeele F. The lumbar multifidus is characterized by larger type I muscle fibers compared to the erector spinae. Anat Cell Biol. 2020;53(2):143\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMannion AF, K\u0026auml;ser L, Weber E, Rhyner A, Dvorak J, M\u0026uuml;ntener M. Influence of age and duration of symptoms on fiber type distribution and size of the back muscles in chronic low back pain patients. Eur Spine J. 2000;9(4):273\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazis N, Papachristou DJ, Zouboulis P, Tyllianakis M, Scopa CD, Megas P. The effect of different physical activity levels on muscle fiber size and type distribution of lumbar multifidus. A biopsy study on low back pain patient groups and healthy control subjects. Eur J Phys Rehabil Med. 2009;45(4):459\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgten A, Stevens S, Verbrugghe J, Timmermans A, Vandenabeele F. Biopsy samples from the erector spinae of persons with nonspecific chronic low back pain display a decrease in glycolytic muscle fibers. Spine J. 2020;20(2):199\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgha O, Mueller-Immergluck A, Liu M, Zhang H, Theologis AA, Clark A, Kim HT, Liu X, Feeley BT, Bailey JF. Intervertebral disc herniation effects on multifidus muscle composition and resident stem cell populations. JOR Spine. 2020;3(2):e1091.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYun YI, Jeon I, Kim SW, Yu D. Risk factors for adjacent segment disease requiring reoperation after posterior lumbar interbody fusion with screw fixation: focus on paraspinal muscle, facet joint, and disc degeneration. Acta Neurochir (Wien). 2022;164(3):913\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang MY, Park Y, Ha JW, Zhang HY, Lee SH, Hong TH, Lee SH. Paraspinal Lean Muscle Mass Measurement Using Spine MRI as a Predictor of Adjacent Segment Disease After Lumbar Fusion: A Propensity Score-Matched Case\u0026ndash;Control Analysis. AJR Am J Roentgenol. 2019;212(6):1310\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGong Z, Li D, Zou F, Liu S, Wang H, Ma X. Low lumbar multifidus muscle status and bone mineral density are important risk factors for adjacent segment disease after lumbar fusion: a case\u0026ndash;control study. J Orthop Surg Res. 2022;17(1):490.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JY, Ryu DS, Paik HK, Ahn SS, Kang MS, Kim KH, Park JY, Chin DK, Kim KS, Cho YE, Kuh SU. Paraspinal muscle, facet joint, and disc problems: risk factors for adjacent segment degeneration after lumbar fusion. Spine J. 2016;16(7):867\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lumbar fusion, Adjacent segment disease revision, Paraspinal muscle quality, Magnetic resonance imaging","lastPublishedDoi":"10.21203/rs.3.rs-9149969/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9149969/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003ePosterior lumbar interbody fusion (PLIF) combined with pedicle screw internal fixation is widely used for treating lumbar degenerative diseases. However, adjacent segment disease (ASDis) requiring revision surgery is a severe complication, and few studies have focused on this complication. Paraspinal muscle mass loss is associated with lumbar diseases and poor postoperative prognosis, but its relationship with ASDis revision remains unclear\u003c/p\u003e\n\u003cp\u003ePurpose To explore the relationship between paraspinal muscle quality and ASDis revision after lumbar fusion and identify its independent risk factors.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003ePatients who underwent revision surgery for the development of ASD at our hospital were enrolled. To evaluate the risk factors for revision, we selected a control group. Each patient in the control group was matched by age, sex, height, weight, BMI, number of fused segments and follow-up duration with a patient in the revision group. Paraspinal muscle parameters, including the cross-sectional area (CSA), functional cross-sectional area (FCSA), CSA-vertebral index (CSA-VI), FCSA-vertebral index (FCSA-VI), and FCSA/CSA ratio, at the third lumbar (L3) and fourth lumbar (L4) levels were measured via MRI. Receiver operating characteristic (ROC) curves and logistic regression were used for analysis.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eAt the L3 and L4 levels, the FCSA, FCSA-VI and FCSA/CSA ratio of the paraspinal, erector spinae and multifidus muscles were significantly lower in the revision group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). The L4 paraspinal muscle FCSA/CSA ratio had the highest area under the curve (AUC) (0.942). Preoperative adjacent facet joint degeneration was greater in the revision group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). Logistic regression revealed that L4 paraspinal muscle FCSA/CSA ratio (odds ratio = 0.731, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and preoperative adjacent facet joint degeneration (odds ratio = 4.664, \u003cem\u003eP\u003c/em\u003e = 0.023) were independent risk factors.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eDecreased paraspinal muscle quality is associated with ASDis revision. L4 paraspinal muscle FCSA/CSA and preoperative adjacent facet joint degeneration can predict ASDis revision. Conclusion: A decreased paraspinal muscle mass is associated with ASDis revision. L4 paraspinal muscle FCSA/CSA ratio and preoperative adjacent facet joint degeneration are independent risk factors for ASDis revision.\u003c/p\u003e","manuscriptTitle":"Paraspinal Muscle Quality and Adjacent Facet Joint Degeneration as Significant Predictors of ASDis Revision After Lumbar Fusion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-02 07:14:13","doi":"10.21203/rs.3.rs-9149969/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-14T05:24:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T22:31:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T01:27:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103804667932045337580061155595087683934","date":"2026-04-02T08:23:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36417928580593030076452135804171345920","date":"2026-03-30T22:08:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228802654626502283175168893203259881335","date":"2026-03-30T14:33:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-30T14:03:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T07:49:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T07:48:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2026-03-17T14:06:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d9330c8-733c-4975-8505-a2d1854d661b","owner":[],"postedDate":"April 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T07:10:56+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-02 07:14:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9149969","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9149969","identity":"rs-9149969","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}