Three-level bilateral pediculolysis following osteoporotic lumbar compression fracture.

BACKGROUND CONTEXT: Osteoporotic compression fractures frequently occur at the thoracolumbar junction as a result of anterior column failure. Fractures of the pedicles are much less common and are not known to be associated with a prior compression fracture. Bilateral pedicle fractures over several consecutive lumbar levels in an osteoporotic elderly patient have not been previously reported. PURPOSE: To draw attention to this unusual case and to review the relevant literature. STUDY DESIGN: A clinical case report of bilateral fractures of the pedicles from L3 through L5 in an 83-year-old male 2 years after an osteoporotic L3 compression fracture presenting with low back pain. METHODS: An 83-year-old male presented with low back pain two years after sustaining osteoporotic compression fracture at L3 due to a fall. He had another minor fall and his radiographic workup revealed bilateral fractures of the pedicles of the L3, L4, and L5 vertebrae. The patient was treated nonoperatively. RESULTS: The patient's symptoms improved without surgical intervention. Subsequent radiographic evaluation with plain films, computed tomography, and bone scan demonstrated union of the fractured pedicles. CONCLUSIONS: In this uncommon case of bilateral lumbar pedicle fractures over three consecutive levels, isolated failure of the posterior rather than the anterior column occurred. This unusual fracture pattern may have been precipitated by the previous vertebral compression fracture. Nonsurgical management may result in acceptable clinical outcome.     

Pedicle fracture after instrumented posterolateral lumbar fusion: a case report

STUDY DESIGN: The case report of a 60-year-old man with late onset back pain after lumbar spine fusion is presented. OBJECTIVE: To report the rare complication of bilateral pedicle stress fractures after instrumented posterolateral lumbar fusion. SUMMARY OF BACKGROUND DATA: A 56-year-old man underwent revision spinal surgery for ongoing back pain secondary to pseudoarthroses. A posterolateral L4-S1 instrumented fusion using pedicle screws was performed. Autologous bone graft was applied to the decorticated lateral masses. The internal fixation was removed 2 years later, at which time plain radiographs showed that the fusion mass was solid. At the age of 60 years, the man presented with worsening back pain. Plain radiographs and computed tomographic scans demonstrated bilateral L4 pedicle stress fractures. A bone scan indicated that these were recent in origin. METHOD: The clinical assessment was undertaken by the senior author and surgeon. Investigations included plain radiography, computer tomography, and scintographic imaging. A systematic literature review of the relevant publications was performed. RESULTS: In the reported patient, bilateral pedicle stress fractures developed 2 years after pedicle screw removal from an L4-S1 instrumented posterolateral lumbar spine fusion. This occurred at the uppermost level of the fusion mass. CONCLUSIONS: The pedicle is the weakest point in the neural arch after posterolateral fusion. Although movement continues at the level of the disc space anteriorly, the pedicle is susceptible to fracture. Pedicle fracture is a rare late complication of posterolateral lumbar spine fusion.     

Iatrogenic spondylolysis leading to contralateral pedicular stress fracture and unstable spondylolisthesis: a case report

STUDY DESIGN: A case report of iatrogenic spondylolysis as a complication of microdiscectomy leading to contralateral pedicular stress fracture and unstable spondylolisthesis. OBJECTIVE: To improve understanding of this condition by presenting a case history and roentgenographic findings of a patient that differ from those already reported and to propose an effective method of surgical management. METHODS: A 67-year-old woman with no history of spondylolysis or spondylolisthesis underwent an L4-L5 microdiscectomy for a left herniated nucleus pulposus 1 year before the current consultation. For the preceding 8 months, she had been experiencing low back and bilateral leg pain. Imaging studies revealed a left L4 spondylolytic defect and a right L4 pedicular stress fracture with an unstable Grade I spondylolisthesis. RESULTS: The patient was treated with posterior spinal fusion, which resulted in complete resolution of her clinical and neurologic symptoms. CONCLUSIONS: Iatrogenic spondylolysis after microdiscectomy is an uncommon entity. However, it can lead to contralateral pedicular stress fracture and spondylolisthesis, and thus can be a source of persistent back pain after disc surgery. Surgeons caring for these patients should be aware of this potential complication.     

Vertebral body fracture after anterolateral instrumentation and interbody fusion in two osteoporotic patients

Background contextThe XLP plate is an anterolateral instrumentation system developed as a part of the eXtreme Lateral Interbody Fusion (XLIF) system for lateral transpsoas interbody fusion, an alternative to anterior interbody fusion.PurposeTo report two cases of atraumatic coronal plane vertebral body fractures in the early postoperative period after interbody fusion using XLIF cages, lateral plating using the XLP plate, and unilateral posterior pedicle screw instrumentation.Study designCase report.Methods/summariesBoth patients were septuagenarian women with normal body mass indices and osteoporosis. The patients underwent L4–L5 XLIF with anterolateral instrumentation followed by posterior decompression and fusion using unilateral pedicle screws. In the early postoperative period (≤6 weeks), the patients developed acute onset of severe low back pain without history of trauma. Imaging demonstrated coronal plane vertebral body fracture through the screw hole of the XLP plate in the superior vertebral body in one case and the inferior vertebral body in the other. One patient required kyphoplasty at the L4 level for pain relief. The other was treated conservatively. The nondisplaced fractures went on to union with pain resolution and successful fusion in both patients.ResultsCoronal plane fractures occurred in 2 of 13 patients treated by the senior author using XLIF, the XLP plate, and unilateral pedicle screw instrumentation. Osteoporosis was likely a contributing factor in both patients. One potential mechanism for this unusual fracture pattern is subsidence of the cage with resultant cut-through of the fixed-angle screws through the osteoporotic vertebral body. Alternately, the fracture could have resulted from the stress riser created by the screw hole traversing an area of relative stress concentration directly adjacent to the cage.ConclusionCoronal plane vertebral fracture may occur in osteoporotic patients treated with XLIF and XLP lateral instrumentation. Unilateral pedicle screw instrumentation does not prevent this complication.     

Bilateral pedicle stress fracture in the lumbar spine of a sedentary office worker

A case of bilateral pedicle fracture in the lumbar spine of a sedentary office worker is being presented. No such case has been reported in the literature previously. Bilateral pedicle fracture is a rare entity. Few cases have been reported in literature. All the reported cases had some underlying causative factors like degenerative spine disease, previous spinal surgery or stress-related activities, e.g. athletes. Our case is a 36-year-old sedentary office worker with none of the factors mentioned. We present a case of a 36-year-old sedentary worker with long-standing low backache. There were no root tension signs. Plain radiographs were inconclusive. The patient had a CT scan. The CT scan revealed long-standing defects in the pedicles of L2 vertebra with pseudoarthrosis. Infiltration with anaesthetic relieved the symptoms. Our patient was managed conservatively with spine rehabilitation physiotherapy program. Pedicle fracture can develop due to abnormal stresses in the pedicle either because of previous spinal surgery or spondylitic changes in the spine. Bilateral pedicle fracture in the absence of these conditions is extremely rare.

     

A case of posterior element fracture in Kummell's disease

Kummell's disease is a rare, delayed posttraumatic collapse of a vertebral body that can occur several months or even years after an osteoporotic compression fracture. However, there are few reports of posterior element fractures associated with Kummell's disease. A 72-year-old man who had sustained an L1 osteoporotic compression fracture 14 months prior was admitted to our institution with incapacitating back pain. Plain radiographs showed progressive collapse of the L1 vertebral body and severe kyphosis at the thoracolumbar junction. Magnetic resonance imaging revealed a posterior element fracture as well as osteonecrosis of the L1 vertebral body. An L1 percutaneous vertebroplasty was performed, followed by bone cement-augmented screw fixation to maintain stability and correct the kyphotic deformity. After surgery, pain relief was immediate, and the patient was able to walk unassisted. This case illustrates that continuous axial distraction stress caused by aggravated kyphosis secondary to Kummell's disease may result in posterior element fractures. Our discussion concludes with a literature review.     

Spine fracture with neurological deficit in osteoporosis

The literature suggests that spinal fractures acquired after minimal trauma in osteoporotic patients cause neurological problems only extremely rarely. This report describes 9 patients with severe osteoporosis in whom minimal trauma led to a fracture of the thoracic or lumbar spine causing significant neurological deficit. All patients presented originally with isolated back pain after minimal trauma. Initial radiographs documented what appeared to be benign compression fractures with minimal loss of vertebral height. Over the following 1–12 weeks all patients described a gradual onset of severe radicular pain which was subsequently associated with profound lower extremity weakness in 7 cases. Repeat radiographs revealed advanced collapse of the fractured level. CT and MRI images revealed violation of the posterior cortex of the vertebrae with retropulsion of bone into the spinal canal. In 2 cases, two simultaneous fractures of this kind were noted; in both of these cases the fractures occurred at adjacent levels. The upper lumbar spine was most frequently involved. This relatively small series suggests that caution should be used in the assessment of benign-appearing compression fractures in osteoporotic patients. The delayed appearance of neurological signs and symptoms may lead to a late or missed diagnosis. The onset of back pain in an elderly patient quite frequently represents the acquisition of a fracture; subsequent complaints of leg pain or lower extremity dysfunction may indicate progression of such a fracture, with compromise of the neutral elements.     

Treatment of lower lumbar radiculopathy caused by osteoporotic compression fracture: the role of vertebroplasty

The authors used vertebroplasty for the treatment of severe lower lumbar radicular pain caused by osteoporotic compression fracture. Patients presented with severe radiating leg pain rather than lower back pain from recent osteoporotic compression fracture of lower lumbar vertebra. Radiologic findings showed osteoporotic compression fracture combined with preexisting stenosis of the intervertebral foramen resulting in root compression. After injection of polymethylmethacrylate into the compressed vertebral body through the pedicle of the symptomatic side, all seven patients experienced dramatic pain relief that lasted throughout the mean follow-up duration of 9.1 months. They conclude that vertebroplasty may be an effective way of relieving radicular pain caused by osteoporotic compression fracture combined with foraminal stenosis.     

Seizure-induced muscle force can caused lumbar spine fracture

Patients suffering form epilepsy have an increased risk for fractures. Beside fractures caused by fall or accident muscles forces alone generated during tonic-clonic seizure can result in severe musculoskeletal injury. Contractions of strong paraspinal muscles can lead to compression fracture of the mid-thoracic spine. We report a patient who had suffered from a tonic-clonic seizure during early morning hours. After a cracking sound the patient woke up in a state of post-ictal disorientation, loss of urine and tongue bite. He was admitted to our facilities with the suspected vertebral fracture albeit he just reported of mild lower back pain. Native X-rays and computer-tomography scans showed instable burst fractures of L2 and L4. The fractures were stabilised with a dorsally instrumented internal fixator from L1 to L5 followed by hemi-laminectomy and ventral spondylodesis. Muscle force alone can result in severe skeletal trauma including vertebral fractures. This example emphasizes the importance of critical examination of patients after grand mal seizures. Seizures-induced injuries can appear clinically asymptomatic and can easily be overseen due to absence of trauma and post-ictal impairment of consciousness.     

强直性脊柱炎合并胸腰椎骨折的临床分析

目的：总结强直性脊柱炎合并胸腰椎骨折的临床特点,避免诊断延误。方法：回顾性分析自2005年4月至2007年6月收治的5例强直性脊柱炎合并胸腰椎骨折病例,男4例,女1例;年龄26～72岁,平均44．8岁。分析内容包括：病史、骨性融合椎体数、骨折特点、风湿活动状态等。结果：强直性脊柱炎患病史平均22．6年。骨性融合椎体数平均18．2节。1例为自驾车交通事故,1例有扭伤史,3例无外伤史为应力骨折。2例合并椎体骨折：骨折线分别经T6、T7或L1椎体;3例合并椎间隙骨折：2例骨折线经L1,2椎间隙,1例骨折线经L2,3椎间隙。未见压缩骨折及脊髓或马尾神经损伤。4例血沉及C-反应蛋白等急性炎症指标与疼痛程度不相称。非甾体抗炎药均无明显止痛效果。在外院均误诊为强直性脊柱炎“复发”,平均延误1．51个月。结论：①骨折好发于强直性脊柱炎中晚期胸腰椎广泛骨性融合者;②好发于下部胸椎和上部腰椎,且多为应力骨折;③可以为合并椎体骨折或椎间隙骨折;④易误认为强直性脊柱炎“复发”而发生误诊、漏诊;⑤中晚期强直性脊柱炎患者腰背痛突然加剧,疼痛程度与急性炎症指标不相称,非甾体抗炎药甚至皮质类固醇疗效欠佳,应考虑到胸腰椎骨折可能。     

Posterior spinal fusion using a pedicle nail system with polymethylmethacrylate in a paraplegic patient after vertebral collapse caused by osteoporosis

Background contextBecause posterior decompression and fusion for vertebral collapse in an osteoporotic spine sometimes results in a pullout of the pedicle screw. Several authors reported that fixation of pedicle screws in severely osteoporotic bone could be improved by inserting polymethylmethacrylate (PMMA) into the hole before inserting the screw. However, pedicle screws were not designed to be used with PMMA.PurposeTo report a patient with vertebral collapse who were treated using a novel-concept, pedicle nail using with PMMA.Study designCase report.MethodsThe patient was a 74-year-old female who experienced back pain after some heavy lifting 3 months before. She was laid up for 2 months because of the back pain and weakness of her lower legs. Radiographs and magnetic resonance imaging showed vertebral collapse and neural severe compression from the posterior wall of vertebra T12. The pedicle nail consists of an outer sheath with evenly spaced holes and an internal, removable, threaded component. The outer sheath and the internal component were connected before insertion. The pedicle nail attaches to and is bound by the PMMA through the holes of the outer sheath. We performed a T11–L1 posterior fusion and laminectomy using the pedicle nail, and we used a hydroxyapatite block to perform a transpedicular vertebroplasty of T12.ResultsBone union was observed on a lateral radiograph without pedicle nail loosening.ConclusionsThe authors speculate that posterior spinal fusion and vertebroplasty using the pedicle nail will be a reasonable choice for delayed paraplegia after osteoporotic vertebral fracture.     

Clinical application of a pedicle nail system with polymethylmethacrylate for osteoporotic vertebral fracture

The instrumentation of the osteoporotic spine may sometimes result in failure due to the loosening or pullout of the conventional pedicle screw. Moreover, augmentation of screws with polymethylmethacrylate (PMMA) has risks of complications. We developed a new and original pedicle nail system with PMMA for osteoporotic vertebral fractures. A clinical evaluation of this novel pedicle nail system utilized in patients with an osteoporotic vertebral collapse was performed to determine the effectiveness and safety of this technique. Thirty-four elderly patients who suffered from osteoporotic compression fractures were treated by posterolateral fusion using the pedicle nail system. The mean follow-up period was 37 months. Of the 25 patients with neurological symptoms, two patients improved two stages at the Frankel level. Fifteen patients improved one stage at the Frankel level, and eight other patients improved, however, their improvement did not exceed a Frankel level. Nine cases with neuralgia symptoms improved from 4.4 to 2.2 points on average on the Denis pain scale (p < 0.01). The fusion rate was 94% as determined by X-rays of flexion and extension, and the correction of the compression fracture site was maintained well. A pedicle nail system stabilizes the spinal column with osteoporosis and reduces the instrumentation failure. The technique for the insertion of the pedicle nail reduces complication from cement augmentation. The authors speculate that the strategy using the pedicle nail system for osteoporotic spine may be effective and safe when the surgery is performed through a posterior approach.     

三种术式治疗骨质疏松性椎体骨折的疗效分析

目的 :探讨经皮空心带侧孔椎弓根钉钉道骨水泥强化术、经皮椎体成形术(percutaneous vertebroplasty,PVP)和经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗骨质疏松性椎体骨折(osteoporotic vertebral compression fractures,OVCF)的临床疗效。方法 :对2012年5月至2013年11月收治的90例OVCF患者的临床资料进行回顾性分析,按手术方法的不同将其分为经皮空心带侧孔椎弓根钉钉道骨水泥强化组(A组)、PVP组(B组)和PKP组(C组),每组30例。术前、术后1 d、3个月、1年采用疼痛视觉模拟评分法(visual analogue scale,VAS)对患者疼痛缓解程度进行评定;通过影像学资料观察责任椎的椎体压缩率、矢状面Cobb角的变化。结果:所有患者手术顺利,无切口感染、深静脉血栓等并发症。末次随访时A组中有2例患者术后留有轻度腰背痛;B组残留中度腰背痛7例,重度腰背痛4例,术后椎体再骨折2例;C组残留中度腰背痛5例,重度腰背痛3例,术后椎体再骨折4例。术后3组VAS评分、责任椎的椎体高度压缩率、Cobb角均较术前明显改善(P0.05)。术后1 d、3个月、1年各项目A组与B、C两组比较差异有统计学意义(P0.05),B组与C组比较差异无统计学意义(P0.05)。术后1 d、3个月、1年各项目在A组内差异无统计学意义(P0.05);在B组与C组内差异有统计学意义(P0.05)。结论:PVP和PKP对OVCF患者术后即刻止痛效果较经皮空心带侧孔椎弓根钉钉道骨水泥强化术明显,但PVP、PKP患者术后随访均残留不同程度腰背痛;经皮空心带侧孔椎弓根钉钉道骨水泥强化术在恢复责任椎前缘高度和矫正椎体后凸畸形、减少术后残余腰背痛方面具有明显的优势。     

Sacral fracture as a rare early complication of lumbosacral spondylodesis

A 57 year old patient with secondary cortisone induced osteoporosis war surgically treated by means of posterior lumbar interbody fusion with internal fixation from L4-S1 for symptomatic instability in the level L4/5 after previous dorsal stabilisation L5/S1. After an unapparent initial postoperative phase, the patient complained of severe pain in the low back and gluteal region 9 day after surgery. Radiographs as well as CT-scans showed a horizontal fracture of the sacrum. After a short period of immobilisation the patient was carefully remobilised with an orthesis and the pain gradually subsided. Conventional radiographs one year later showed complete consolidation of the fracture and a good clinical result. There are only two literature reports with together 3 cases of patients attaining an early sacral fracture after spondylodesis. The main cause seems to be the unphysiological biomechanical stress placed on the osteoporotic sacrum after moresegmental spondylodesis. Further risk factors seem to be adipositas, female gender and age. Despite the rarity of sacral fractures after lumbosacral fusion, this complication should at least be considered in the differential diagnosis in patients who complain of persisting or sudden-onset pain after surgery.     

L5 root compression resulting from an L2-L3 disc herniation

We present the rare case of a patient affected by low back pain and bilateral L5 sciatica from an L2-L3 herniation. Only 2 cases of monoradicular L5 compression in the high lumbar spine have been reported. The initial computed tomography study of the L4-L5 and L5-S1 spaces revealed no significant alterations. Magnetic resonance imaging showed a disc herniation at L2-3. The electrophysiological study confirmed clinical suspicions of L5 root involvement. A bilateral laminotomy with discectomy on both sides of the L2-3 space was performed. Pain disappeared completely after surgery. The patient remains asymptomatic 2 years after the operation.     

Role of major revision spine surgery in recurrent adjacent segment osteoporotic vertebral body fracture: a case report

Study design

Case report.

Clinical question

To report the beneficial effects of kyphoplasty, cement augmentation and extension of posterior instrumentation in a patient with recurrent adjacent segment osteoporotic vertebral body fracture.

Methods

A 72-year-old lady underwent multiple revision spine surgeries for recurrent adjacent segment osteoporotic vertebral body fracture.

Results

The patient underwent four surgeries in 6?years: (1) in 2005, posterior lumbar interbody fusion with stabilization (L4–S1) was done; (2) in August 2010, implants from L4–S1 were removed and revised, transforaminal lumbar interbody fusion was done at L2/L3 and L3/L4 along with pedicle screw stabilization from T12–S1; (3) in September 2011, revision surgery was attempted, wherein a kyphoplasty was done at T12 and the stabilization was extended to T4; (4) again in October 2011, a revision surgery was attempted, wherein a kyphoplasty was done at T5 along with stabilization using pedicular screws in the T2 and T3 vertebrae and lateral mass screws in the C6 vertebra. To current date, the patient is stable with good sagittal and coronal balance and walking pain free without support.

Conclusion

The current case demonstrates the need for posterior spinal reconstruction in osteoporotic vertebral collapse. Cement augmentation and extension of posterior instrumentation are both viable techniques that could be used to improve stabilization in the elderly spine.     

Osteoporotic vertebral fracture adjacent to a nonsegmented hemivertebra

A combination of osteoporotic vertebral fractures and congenital spinal deformity is theoretically possible, but there have been no reports on this combination in the literature. We describe a rare case of an osteoporotic vertebral fracture adjacent to the nonsegmented hemivertebra. A 60-year-old postmenopausal woman who did not recall any specific trauma presented with severe back pain. She had markedly decreased bone mineral density and significant lumbar kyphoscoliosis with a nonsegmented hemivertebra between L1 and L2 on radiographs of the lumbar spine. Magnetic resonance imaging (MRI) revealed a vertebral fracture adjacent to the nonsegmented hemivertebra. Laboratory studies showed increased serum bone-specific alkaline phosphatase (BAP) and urinary type I collagen crosslinked N-telopeptide (NTx). A thoracolumbar brace was applied for 3 months. Daily administration of alendronate normalized her serum BAP and urinary NTx levels. MRI scans of the lumbar spine after 6 months also confirmed normalized signal intensities of the fractured vertebra adjacent to the nonsegmented hemivertebra. The vertebral fracture seemed to be induced by spinal malalignment, increased stress on the adjacent level of the fused segment, and its fragility due to osteoporosis.     

Herniated disc of lumbar spine caused by bone cement leakage after kyphoplasty – A case report and literature review

Introduction and importanceTo describe an unusual case with herniated disc caused by bone cement leaking to disc space after kyphoplasty.Case presentationWe reported a 72-year-old woman with L4 osteoporotic compression fracture. New-onset of left sciatica, numbness and intermittent claudication suffered her immediate after kyphoplasty. Herniated disc caused by bone cement leaking to disc space after kyphoplasty. The patient was post decompressive operation of L34 and the symptoms subsided well then.Clinical discussionPercutaneous vertebroplasty (PVP) was a common procedure today. Especially to back pain caused by osteoporotic fracture, reported pain relief rate was satisfactory. Current studies about bone cement leakage showed kyphoplasty less than vertebroplasty. However, for the mechanism and stress effect of balloon expansion, new weak points and cracks over endplate was created, which may cause bone cement leakage to disc space and related symptoms.ConclusionKyphoplasty was a common, effective and minimal invasive operation for patients with compression fracture of spine. Cement leakage to intervertebral disc space was generally asymptomatic, but it should be avoided as much as possible. The leakage could affect the stability and weight-bearing of spinal column. Accelerated degenerative process of disc would be found and newly herniated disc would be noted. It should be ceased the procedure when relative amount of bone cement leakage to disc space during kyphoplasty.     

鲑鱼降钙素在骨质疏松性椎体压缩骨折椎体后凸成形术后的应用

目的观察鲑鱼降钙素对骨质疏松性椎体压缩骨折行椎体后凸成形术后骨密度及腰背痛症状的改善情况。方法将行椎体后凸成形术后的骨质疏松性椎体压缩骨折患者79例分成两组,鲑鱼降钙素组44例,予以鲑鱼降钙素肌肉注射,术后每天1次100IU,连用3 d后,改为50 IU隔天1次,连用1个月,间歇1个月后再重复,共半年,同时加服维D2磷葡钙;对照组35例,单纯口服维D2磷葡钙,疗程半年。两组治疗前后均测定腰1～腰4椎体及股骨颈骨密度(BMD);并观察患者腰背痛的情况。结果:鲑鱼降钙素组有6例因肌注降钙素出现面部潮红和皮肤瘙痒等反应停止疗程,其余38例和对照组35例得到了随访。鲑鱼降钙素组腰椎及股骨颈BMD较治疗前明显升高(P<0.01),对照组各部位骨密度较治疗前无明显改变(P>0.01)。鲑鱼降钙素组没有病例再次出现腰背痛,而对照组在半年内有7例再次出现腰背痛,经腰椎MRI证实发生其他节段的椎体压缩骨折。结论:鲑鱼降钙素与钙剂联合治疗行椎体后凸成形术后的骨质疏松性椎体压缩骨折患者,可以提高患者的骨量,降低再骨折的风险。