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Broken rod after scoliosis correction with back pain


Introduction

Rod fracture following complex spinal deformity correction is a common problem occurring in up to 15% of cases. Following deformity correction, the rods act as struts that allow the bony fusion to occur. The rods during this time period undergo stress, which may ultimately lead to metal fatigue resulting in rod fracture before solid bony fusion has occurred. While this may be identified during routine follow-up imaging, most patients who have had a rod fracture typically notice a loud pop, which may result in pain. In addition to back and radicular pain, fracture of the rod prior to solid bony fusion may also lead to new deformity from loss of prior deformity correction. The decision on surgical intervention for a fracture rod is one that is dependent on the patient’s symptoms and presence of instability.

Example case

  • Chief complaint: back pain and postural change

  • History of present illness: This is a 70-year-old female with a history of multiple spinal fusion. She is now fused from occiput to pelvic. She had been having multiple falls and now complains of increasing back pain. Additionally, she had noticed she was no longer able to stand straight. Computed tomography scans and x-rays were obtained, which showed a rod fracture ( Figs. 43.1–43.2 ). She attempted conservative management but continued to have severe back pain.

    Fig. 43.1, Preoperative computed tomography scans. (A) Sagittal, (B) coronal, and (C) axial images demonstrating rod fracture and a vacuum disc at T12-L1.

    Fig. 43.2, Preoperative standing x-rays. (A) Lateral and (B) anteroposterior (AP) standing x-rays demonstrating rod fracture with progressive sagittal imbalance.

  • Medications: atorvastatin, Xanax

  • Allergies: ketamine, naproxen, ciprofloxacin

  • Past medical and surgical history: chronic pain, glaucoma, pack pain, chronic kidney disease, hyperlipidemia, laminectomy, fusion, anterior cervical decompression and fusion

  • Family history: noncontributory

  • Social history: nonsmoker

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation intact to light touch

  • Jason Cheung, MD

  • Orthopaedic Surgery

  • The University of Hong Kong

  • Queen Mary Hospital

  • Pokfulam, Hong Kong SAR, China

  • Hazem Eltahawy, MD

  • Neurosurgery

  • St. Mary Mercy Hospital

  • Ain Shams University

  • Livonia, Michigan, United States

  • Lawrence G. Lenke, MD

  • Orthopaedic Surgery

  • Columbia University

  • New York City, New York, United States

  • Timothy F. Witham, MD

  • Neurosurgery

  • Johns Hopkins

  • Baltimore, Maryland, United States

Preoperative
Additional tests requested

  • Obtain older x-rays and operative notes

  • MRI complete spine

  • Nephrology evaluation

  • CT myelogram T-L spine

  • DEXA

  • Cardiopulmonary evaluation

  • Ophthalmology evaluation

  • CT complete spine (occiput-pelvis)

  • DEXA

  • Cardiac evaluation

  • Lower extremity dopplers

  • Pulmonary function test

  • CT myelogram T-L spine

  • DEXA

  • Calcium, vitamin D, PTH serum levels

  • Medicine evaluation

Surgical approach selected C5-T4 revision instrumentation and fusion L3 pedicle subtraction osteotomy, TLIF at pseudoarthrosed levels, revision of right-sided screws, correction of kyphosis, T3-L4 fusion If patient elected to pursue, revision T6-sacrum/ilium, possible TLIF, several posterior column osteotomies After weight reduction and osteoporotic management, T10 three-column osteotomy and thoracolumbar fusion with possible reinstrumentation

  • Surgical approach if 25

  • Surgical approach if 50

  • Revision osteotomy at lumbar spine, possible interbody fusion

  • Revision osteotomy at lumbar spine, possible interbody fusion, possibly in staged fashion

  • Same approach

  • Same approach, but osteoporosis management may not be necessary and the correction of kyphosis may need to be more aggressive

  • Same approach

  • Same approach, but osteoporosis management may not be necessary and the correction of kyphosis may need to be more aggressive

  • Same approach except osteoporotic management and more aggressive kyphosis correction

  • Same approach but more aggressive with kyphosis correction

Goal of surgery Stabilize segment, enhance fusion Correction of sagittal imbalance, repair of pseudoarthrosis, hardware replacement Repair pseudoarthrosis, realign sagittal global malalignment Correct deformity, stabilize spine, revise arthrodesis
Perioperative
Positioning Prone, with Mayfield pins Prone, with Mayfield pins Prone on OSI frame, with Gardner-Wells tongs Prone on Jackson table, no pins
Surgical equipment

  • IOM (MEP/SSEP)

  • Ultrasonic bone scalpel

  • Cables and wires

  • Bone saw

  • IOM (MEP/SSEP)

  • Cell saver

  • Pedicle osteotomy set

  • Surgical navigation

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • IOM

  • Fluoroscopy

  • Osteotomes

Medications Tranexamic acid, BMP MAP >80 Tranexamic acid, steroids Tranexamic acid
Anatomical considerations Spinal cord, pedicle integrity Dura, nerve roots, segmental vessels, great vessels Prior laminectomy defects Spinal cord, segmental vessels, aorta, inferior vena cava
Complications feared with approach chosen Spinal cord injury, implant failure, prolonged ventilation, renal failure CSF leak, medical complications, wound breakdown Nerve root injury, CSF leak, medical complications Instability, failed fusion, recurrent deformity
Intraoperative
Anesthesia General General General General
Exposure C5-T4 T3-L4 T5-sacrum T-L
Levels decompressed None L2-4 T10-L3 T10
Levels fused C5-T4 T3-L4 T6-sacrum T-L
Surgical narrative Preflip IOM, position prone with Mayfield pins to stabilize skull, expose cervicothoracic spine, remove cross-link at T5-6, loosen caps and disengage rod, check screws at C5-6 to see if loosened, likely replace T2-4 screws with bigger caliber screws except T4 screws where the fracture is located, pack bone graft through pedicle hole, tapered rod to connect entire segment or use cross connectors to connect upper and lower segments with two additional rods, possible laminar wires if no screws can be inserted, try to move expeditiously to avoid blood loss, four-rod construct, promote fusion with fibula allograft to span unstable segment with cancellous bone and BMP, vancomycin powder before closure Position prone, baseline SSEP and MEP, place iliac crest reference frame for spin navigation, skin incision centered over lumbar and thoracic midline using old scar, thorough hemostasis during exposure of bone and hardware, unlock set screws and remove rods, cut rod at T4 and reconnect later, O-arm spine, L2-4 laminectomy with bilateral facetectomy and excision of scar on top of dura, replace L2 and L4 screws with dual head screws, L3 pedicle osteotomy with removing L2-3 disc, TLIF at thoracolumbar pseudoarthrosed level, revise right-sided screw confirm anatomical alignment with x-ray or O-arm, insert bilateral contoured rods, connect to rest of construct at T3, supplement with dual rods across thoracolumbar junction, insert one submuscular and one subcutaneous drain, layered closure Position prone, subperiosteal dissection from T5 to sacrum/iliac, place vancomycin powder into muscles and subcutaneous tissue, check for implant failure, removal all rods from T6 to scrum/ilium, check for fusion status level by level, clean up scar over suspected pseudoarthrosis level, perform posterior column osteotomies from T10-L3, check all pedicle screws and replace with larger diameter if needed, reinstrument T6 bilaterally, cantilever placement of correcting rods to maximize lordosis, construct-construct compression to close osteotomies and pseudoarthrosis sites, two rods in upper T-spine going to three rods at lower T-spine to four rods covering TL junction to sacrum/lilium, intraoperative long cassette coronal and sagittal x-rays, adjust as needed, revision posterior fusion at all pseudoarthrosis and osteotomy sites with auto/allograft and potentially BMP, layered closure with one deep and one superficial drain, place vancomycin and tobramycin powder into muscles and subcutaneous tissue prior to closure Position prone, localizing x-rays and establishment of on-table alignment, exposure of levels deemed necessary for revision, cut rods, remove instrumentation as needed, reinstrument if needed, laminectomy at level of osteotomy likely around T10, perform extended pedicle subtraction osteotomy, place small Harms cage, close osteotomy with instrumentation and continuous IOM, x-ray to confirm hardware and alignment, decortication, place BMP, layered closure with drain
Complication avoidance Preflip IOM, check previous hardware for loosening, bone graft in pedicle where the fracture is located, possible laminar wires if screws cannot be inserted, four-rod construct, BMP to promote fusion Cut rod at T4 to connect to later, L3 pedicle osteotomy for deformity correction, connect to construct at T3, supplement with dual rods across thoracolumbar junction Check for implant failure, check fusion status level by level, check all pedicle screws and replace with larger diameter if needed, cantilever placement of correcting rods to maximize lordosis Revise instrumentation as needed, three column pedicle subtraction osteotomy, revise instrumentation as needed based on intraoperative determination
Postoperative
Admission ICU ICU ICU ICU
Postoperative complications feared Spinal cord injury, implant failure, prolonged ventilation, renal failure Wound healing issues, CSF leak, neurological deficits, medical complications Nerve root injury, CSF leak, medical complications Spinal cord injury, CSF leak, recurrent pseudoarthrosis, instrumentation failure
Anticipated length of stay 2 weeks 5–7 days 6 days 5–7 days
Follow-up testing

  • Cervicothoracic x-rays every 3 months for first year after surgery

  • CT C-T spine 6 months after surgery

  • 36-inch standing x-rays 3 months, 6 months, 1 year after surgery

  • CT C-T-L spine 1 year after surgery

Upright x-rays after drain removed

  • CT T-L spine prior to discharge

  • Scoliosis x-rays prior to discharge, 6 weeks, 3 months, 6 months, 1 year after surgery

Bracing Body jacket with cervical component for at least 6 months until union achieved None None None
Follow-up visits Every 3 months for 1 year after surgery 2 weeks, 6 weeks, 3 months 6 months, 1 year after surgery 2 weeks, 6-8 weeks after surgery 2 weeks, 6 weeks, 3 months, 6 months, 1 year after surgery
BMP , Bone morphogenic protein; CSF , cerebrospinal fluid; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; EMG , electromyography; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potential; OSI , orthopedic system Inc; PTH , parathyroid hormone; SSEP , somatosensory evoked potential; TLIF , transforaminal lumbar interbody fusion.

Differential diagnosis

  • ▪

    Rod fracture

  • ▪

    Pseudoarthrosis

  • ▪

    Osteomyelitis

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