A predictable cascade of junctional failure following progressive long-segment fusion: an 11-year case analysis

Abstract Instrumented spinal fusion is a common treatment for degenerative spinal disease but may lead to progressive mechanical and biological complications, especially in long multilevel constructs. We report the case of a 62-year-old woman who developed serial adjacent segment degeneration, pseudarthrosis, implant failure, vertebral fractures, and progressive deformity over 11 years following posterior lumbar fusion. Multiple revision surgeries with stepwise cranial extension to the upper thoracic spine were required. Despite advanced fixation techniques—including multi-rod constructs, iliac fixation, and CT-navigated instrumentation—recurrent mechanical failure occurred. The final presentation involved an unstable thoracic fracture with impending spinal cord injury, necessitating urgent revision with vertebral body replacement and cranial extension into the cervical region. This case highlights the cumulative biomechanical and biological burden of long-segment fusion and underscores the importance of careful patient selection, bone health optimization, and long-term follow-up.