The patient is a 52-year-old female. Previously, she had an L3-L5 posterior spinal fusion. Two years later, she developed spinal stenosis with a herniated disc at L2-L3 and was treated by another physician with a wide laminectomy at L2-L3.
She presented to my office with incapacitating low back pain and a gross kyphotic deformity and imbalance. She was unable to stand erect.
The patient had poor range of motion. She had a gibbus deformity and was unable to obtain neutral upright position.
The patient had had two previous spine surgeries: an L3-L5 posterior spinal fusion and an L2-L3 wide laminectomy, both done by another physician. Following the L2-L3 laminectomy, she tried non-operative care (physical therapy and facet injections) but with no pain relief.
Figure 1: AP x-ray showing previous L3-L5 posterior spinal fusion with the imblance and lateral listhesis at L2-L3.
Figure 2: Lateral x-ray showing a gross 36º kyphotic deformity L2-L3.
Figure 3: Flexion-extension x-rays. She had slight improvement with flexion-extension.
Figure 4: Left bending x-ray showing that her listhesis improves with bending.
Figure 5: MRI showing severe degenerative changes at L2-L3.
Figure 6: CT scans demonstrating degenerative changes showing that her instability is reducible.
The patient was diagnosed with post-laminectomy instability.
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The patient had a thoracolumbar posterior lateral fusion with TLIF at L2-L3.
She needed structural support to extend into her thoracic spine because of her gross instability. To stop at L2 would have been inappropriate because L1-L2 was very degenerative. That could lead to transitional syndrome and repeat this kyphotic deformity.
Figure 7: 1-year post-operative x-ray.
Figure 8: 1-year post-op lateral x-ray.
Figure 9: Pre-operative (left) to post-operative (right) x-ray showing correction of instability and deformity.
Figure 10: Pre-operative (left) to post-operative (right) lateral x-rays showing reduction of kyphotic deformity.
The patient went back to work and ended pain management. She’s extremely pleased with her results..
This patient developed proximal junctional kyphosis accentuated by the laminectomy at L2-L3. Thirty-six inch standing radiographs would have been helpful to determine the extent of both focal kyphosis correction and global sagittal plane correction needed to correct the deformity. Best surgical results occur when normal sagittal balance, the pelvic tilt is less than 25 degrees, and the lumbar lordosis is proportional to the pelvic incidence is achieved. There appears to be loss of lumbar lordosis in addition to the proximal junctional kyphosis that complicates this case.
The extension of the fusion to the thoracic spine and L2-L3 TLIF clearly corrected the junctional kyphosis and the scoliosis. Standing radiographs would better demonstrate whether this surgical procedure also gave sufficient correction of the overall global sagittal balance. It is possible that a more extensive procedure including osteotomies may have been needed to achieve optimal sagittal balance. At times, a pedicle subtraction osteotomy (at L2 in this case) or multiple level Smith-Petersen osteotomies (including through the fused lumbar segments) will be needed to achieve sufficient correction.