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Revision Surgery for Pseudarthrosis after Thoracolumbar Fracture Stabilization


The patient is a 30-year-old male who sustained L1 and L2 fractures during a helicopter crash. He was treated elsewhere with a T12-L3 instrumented fusion procedure for fracture stabilization. One year later, he presented to us with persistent, debilitating back pain that was worse with movement; specifically, flexion and extension. He was taking NSAIDs for pain relief, but not any opioid medications.


Motor and sensory exams were normal. He had no pathologic reflexes. His prior incision was well healed.

Pretreatment Imaging

Standing x-ray showed focal kyphosis at the level directly above the top of his screw-rod construct at T11-T12. This resulted in a Cobb angle of 30-degrees from T11-L3 (Figure 1).

standing lateral x-ray shows 30-degree Cobb angleFigure 1. Standing lateral x-ray; Cobb angle of 30-degrees. Image © Used with Permission, Ali A. Baaj, MD, and SpineUniverse.com.

There was no significant sagittal imbalance. The rods appeared to be straight and without any contouring (Figure 2).

standing x-ray, implanted rods straight, without contouringFigure 2. Standing x-ray shows implanted rods appear straight and without contouring. Image © Used with Permission, Ali A. Baaj, MD, and SpineUniverse.com.

CT imaging re-demonstrated where the L1 and L2 fractures were not completely healed. Also, there was no evidence of bony fusion across the posterior joint complexes (Figure 3).

CT imaging show L1 L2 fractures unhealedFigure 3. CT scans show L1 and L2 fractures are not healed. Image © Used with Permission, Ali A. Baaj, MD, and SpineUniverse.com.

There appeared to be a difference in Cobb angle between the supine CT scans and standing x-rays.


Pseudarthrosis with back pain after thoracolumbar fracture stabilization.

Suggest Treatment

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Selected Treatment

Removal of T12-L3 instrumentation, correction of thoracolumbar kyphosis with facetectomies, T10-L3 stabilization with pedicle screws and rods and arthrodesis with morselized autograft and allograft.

Surgeons’ Treatment Rationale

Unfortunately, we did not have access to the patient’s original preoperative imaging. During our evaluation of the patient and his index procedure, we were curious if bracing alone—initially—would have been a better choice than creating a biomechanically unsound construct at the thoracolumbar junction.

The patient’s mechanical back pain, with evidence of non-fusion, were indications for revision surgery. In addition, the patient developed a focal kyphosis at the level above his prior construct (T11). The rods initially implanted were not contoured, and therefore did not take into consideration the kyphosis that naturally occurs proximal to the straight thoracolumbar junction.

Furthermore, there was no bony fusion across the posterior joints of the instrumented levels, coupled with non-healing fractures of the L1 and L2 vertebrae. The constellation of these radiographic findings suggests a degree of micro-instability in this region that manifests as movement-related or mechanical back pain.

Intraoperatively, the lack of bony fusion was confirmed and there was hypermobility at the thoracolumbar junction with manual manipulation. Fixation across the new kyphotic segment was performed with screws placed at T10 and T11. Importantly, the new rods implanted were contoured to more closely match the patient’s alignment in the thoracolumbar region.

To address the pseudarthrosis and more strongly facilitate fusion across these levels, autograft, a highly porous synthetic bone graft substitute and bone morphogenetic protein (BMP) were placed along the posterior joints.

Pre and Postoperative Comparative Imaging

pre and postoperative images shows Cobb angle reduced from 30- to 13-degreesFigure 4. Preoperative 30-degree Cobb angle surgically reduced to 13-degrees. Image © Used with Permission, Ali A. Baaj, MD, and SpineUniverse.com.

standing pre and postoperative rod implantsFigure 5. (Left) Standing preoperative (index) x-ray and (Right) postoperative (revision) x-ray. Image © Used with Permission, Ali A. Baaj, MD, and SpineUniverse.com.


The surgical outcome demonstrated significant improvement in radiographic spinal alignment decreasing the Cobb angle from 30-degrees to 13-degrees.

The patient did well postoperatively and remained neurologically intact with marked improvement in mechanical back over the initial month before returning to his home country. Opioids were taken for incisional pain ‘as needed’ and he was completely weaned off all pain medications by 2 weeks postoperative. The patient did not require a brace.

Peer Case Discussion

I agree with the authors’ decision to proceed with revision surgery. Bracing (alone) was highly unlikely to provide any benefit. The original construct for treating these two fractures was inadequate to prevent proximal failure and increased kyphosis.

The absence of radiographic fusion was another indication for revision surgery. Taking the construct up to T10 was the critical component of the revision strategy, along with aggressive revision of the bony fusion using both autograft and bone morphogenetic protein.

Lastly, I question what the indications were for the original surgery, as the original postop films with the proximal kyphotic deformity failed to show any loss of L2, L3 vertebral body greater than perhaps 10-20%, so perhaps the patient would have been better off being treated nonoperatively from the start. We don’t have those films to review, but I suspect the index surgery caused more problems than the original scenario.

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