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Kyphoplasty is a minimally invasive technique for the treatment of pathological compression fractures and osteoporotic compression fractures of the spine. This procedure represents a valuable treatment option for patients and their families, especially in terms of pain relief and improvement of the quality of life. Kyphoplasty successfully relieves acute pain in the vast majority of patients with pathological and osteoporotic fractures and increases the biomechanical stability by partially restoring vertebral height. Several complications can occur including extrusion of cement into the spinal canal, hematoma, osteomyelitis, and adjacent vertebral fractures. However, refracture after cemented vertebral augmentation by kyphoplasty is relatively rare. Refracture occurs at 3.4 months after kyphoplasty on average and has an incidence rate of 12.5%. The pathogenesis of this condition is linked to technical factors and patient-related conditions, such as advanced osteoporosis, high body mass index, and low bone mineral density (BMD). Conservative treatment, such as antiosteoporosis medication and back brace, are effective for the treatment of refracture. Nevertheless, surgical decompression and stabilization can be required in the setting of a new neurological deficit. Herein, we present the case of a 69-year-old woman with acute back pain 1 day after a kyphoplasty.
Chief complaint: back pain
History of present illness: This is a 69-year-old female who has acute worsening of back pain after an L1 kyphoplasty 1 day prior. She has no leg symptoms and no genitourinary symptoms. Because of the worsening back pain, she underwent x-rays ( Fig. 26.1 ) and magnetic resonance imaging ( Fig. 26.2 ) that demonstrated refracture at the previous kyphoplasty site. Computed tomography scans (not shown) showed bilateral L1 pedicle and posterior element fractures.
Medications: bisphosphonates
Allergies: no known drug allergies
Past medical and surgical history : mastectomy for stage 1 BRCA neg cancer 10 years previous
Family history: none
Social history: no smoking, no alcohol
Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/biceps/triceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
Reflexes: 2+ in bilateral biceps/triceps/brachioradialis; 2+ in bilateral patella/ankle; no clonus or Babinski; negative Hoffman; sensation intact to light touch; FABER negative; hip motion testing negative; straight leg raise negative
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Preoperative | ||||
Additional tests requested |
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None |
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Adjuvant therapy |
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None |
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None |
Surgical approach selected | Conservative management | If convinced this is the source of pain and depending on standing balance and SVA, Stage 1: T10-L3 fusion with posterior column osteotomies as needed Stage 2 (if needed based on SVA): T12-L2 discectomy with interbody fusion and possible L1 corpectomy | Conservative management | If convinced this is the source of pain, L1 corpectomy and T10-L2 fusion |
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Goal of surgery | Stabilization, improve sagittal balance | Decompression, stabilization | ||
Perioperative | ||||
Positioning |
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Lateral | ||
Surgical equipment |
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Medications | None | None | ||
Anatomical considerations | Never roots, spinal canal, great vessels, bowel, kidneys | Vascular anatomy, diaphragm insertion | ||
Complications feared with approach chosen | Bow injury, injury to great vessels, nerve root injury, pseudoarthrosis, spinal instrumentation failure, adjacent level kyphosis | Inferior vena cava injury | ||
Intraoperative | ||||
Anesthesia | General | General | ||
Exposure |
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T12-L2 | ||
Levels decompressed |
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L1–2 | ||
Levels fused |
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T12-L2 | ||
Surgical narrative |
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Lateral position similar to an OLIF, psoas muscle identification after peritoneum retraction, corridor between peritoneum and psoas enlarged with dissection and vascular retraction until L1 vertebral body well defined, sometimes diaphragm pillar needs to be cut for the T12-L1 disc to be exposed, ligate lumbar artery at L1 level, place MIS retractor, L1 corpectomy and removal of cement, care with thecal sac, preparation of the T12 and L2 end plates for mesh, lace mesh filled with allograft bone, bone material send for pathological analysis, closure of muscle layers without drain, percutaneous posterior T10-L2 fusion | ||
Complication avoidance | Support top of construct with cement, determine Smith-Peterson osteotomies as needed based on positioning in Jackson table, staged procedure if more anterior support needed based on standing x-rays, palpate bulging discs beneath psoas | Lateral approach, care with thecal sac, percutaneous posterior fusion to supplement, concern for breast cancer metastasis | ||
Postoperative | ||||
Admission | Floor | ICU | ||
Postoperative complications feared | Adjacent vertebral fracture, loss of fixation, proximal or distal junction kyphosis | Deep vein thrombosis, hardware pull out, adjacent fracture | ||
Anticipated length of stay | 3 days | |||
Follow-up testing |
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Standing x-rays 3 weeks after surgery | Thoracolumbar x-rays in 2–4 weeks |
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Bracing | TLSO brace for 6 months | TLSO brace for 6 weeks | Jewett brace for 4 weeks | None |
Follow-up visits | 4 weeks, 3 months, 6 months | 3 weeks after surgery | 2–4 weeks | 2 weeks, monthly for 6 months after surgery |
Osteoporotic fracture
Metastatic lesion
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