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Lumbar Construct Failure

History

The patient is a 57-year-old male, with a significant history of cirrhosis of the liver. He was transferred to our institution with lumbar construct failure.

Initially, he presented with severe low back pain secondary to degenerative disc disease and underwent a L4-L5 posterior laminectomy, instrumentation, and fusion. He developed an infection with osteomyelitis and returned to surgery for a posterior instrumentation revision with extension from L3-S1 and anterior L4-L5 interbody fusion. The construct failed with L4-L5 subluxation and graft extrusion.

Examination

The patient's symptoms include severe low back pain and bilateral radiculopathy. He is not able to stand or ambulate because of the pain. His Visual Analog Score (VAS) is 9/10. While he has pain-related weakness, there is no focal neurologic deficit or bowel and/or bladder dysfunction.

Prior Treatment

Upon arrival, we performed percutaneous biopsy of L4-L5 to confirm the infection was not active.

Images

Lumbar anterior posterior (Fig. 1A) and lateral (Fig. 1B) x-rays demonstrate the construct failure at L4-L5.

lumbar anterior posterior x-ray demonstrates construction failure at L4-L5Figure 1A

lumbar lateral x-ray demonstrates construction failure at L4-L5Figure 1B

A lumbar lateral CT scan demonstrates similar findings at L4-L5. (Fig. 2)

lumbar lateral CT demonstrates construction failure at L4-L5Figure 2

Diagnosis

Failure of lumbar construct with graft extrusion and subsidence.

Suggest Treatment

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Selected Treatment

We performed an anterior removal of the interbody cage, L4 corpectomy with anterior column support, and posterior revision of instrumentation with fusion from L2-Iliac.

Outcome

At one year follow-up, the patient's Visual Analog Score reduced to 3/10 (from 9/10). He ambulates without assistance. There are no signs of infection or construct failure. Anterior posterior (Fig. 3A) and lateral (Fig. 3B) x-rays provide evidence of fusion.

one year post-operative anterior posterior lumbar x-ray; L4-Iliac instrumentation and fusionFigure 3A

one year post-operative lateral lumbar x-ray; L4-Iliac instrumentation and fusionFigure 3B

Discussion

This is a case of an extremely unfortunate patient who initially presented to the surgeon's institution following multiple surgeries for L4-L5 discitis/osteomyelitis and lumbar construct failure. After being transferred with persistent low back pain and bilateral leg pain, a work-up, including plain radiographs, a CT scan with 2D reconstructions, and a percutaneous biopsy of L4-L5 was initiated.

The anterior posterior and lateral radiographs reveal evidence of what appears to be extrusion and subsidence of a femoral ring allograft from the L4-L5 interspace and anterolateral listhesis, as well as significant erosion, of the L4 vertebral body. Since only plain films and a 2D sagittal reconstruction image were provided, we are left with some unanswered questions about the patient's neurologic status. Namely, since the patient presented with bilateral radiculopathy, it would have been helpful to assess the extent and precise location of neurologic involvement with an MRI scan.

In a compromised patient (ie, liver cirrhosis) with failed index and secondary procedures, I would not have taken any chances of an occult infection that could have been missed from a percutaneous biopsy. Although the biopsy was presumed to be negative, I would have also ordered blood work including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein -- not only to rule out infection, but also to obtain baseline levels to track the course of treatment post-operatively. Gadolinium-enhancement and STIR MRI sequences could also have helped to determine the extent of edema/osteomyelitis for pre-operative planning.

Of the treatment options presented, the one chosen by the surgeon appears to be the most rational and comprehensive. Anterior removal of the allograft, L4 corpectomy, and revision instrumentation and fusion effectively solves the issues associated with the failed anterior construct and stabilizes the spine segmentally in a 360-degree fashion. I am assuming that the surgeon also took the time to decompress any neural elements that were found to be compromised on the advance imaging studies in order to address the patient's concomitant radicular symptoms.

Another viable option that was not mentioned, but could serve as an adjunct to the work that was performed, is the lateral approach to the anterior column (eg, XLIF, DLIF). With the advent of deployable retractors and expandable cages, the aforementioned anterior procedures can now be performed through less invasive means through a lateral approach.

Community Case Discussion (1 comment)

SpineUniverse invites spine professionals to share their thoughts on this case.


A very challenging case, especially re-visiting through a midline retroperitoneal exposure. I agree that the direct lateral might have provided easier access, but a think that it would have been difficult to utilize either XLIF or DLIF for this case. The construct appears to be caudal to the iliac crest on the lateral. A lateral trans-psoas approach using the Syn-Frame (or similar retractor) for exposure would have allowed for access to the affected area without having to risk the anterior vessles. The absence of pedicle screws in both L4 and L5 in the initial fusion speaks to why this failed so spectacularly. Obviously, the infection ultimately lead to the failure, but I suspect that the failure would not have been as impressive if those two vertebral bodies had been instrumented.

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