Download Major Spinal Surgery Procedure on a High

JOSS
10.5005/jp-journals-10039-1032
Sumeet G Pawar et al
Case report
Major Spinal Surgery Procedure on a High Cardiovascular
Risk Patient with Symptomatic Neural Compression
due to 1: Osteoporotic T12 Compression Fracture
along with 2—L5/S1 Spondylolisthesis
1
Sumeet G Pawar, 2Premanand Ramani, 3I Sabri Ibrahim
ABSTRACT
INTRODUCTION
Introduction: Osteoporotic vertebral fracture most common
located at thoracolumbar junction, whereas most spondylolisthesis at L4-5 is six to 10 times more frequent involved than
adjacent level. Concomitant compressed fracture with lumbar
spondylolisthesis is rarely reported.
Lumbar spondylolisthesis requiring surgery is common.
It is also common to get compression fracture in the DL
region, particularly in elderly osteoporotic patients following a minor trauma like fall in the house. What is not
common is to find patients presenting with symptoms
of both spondylolisthesis and DL region compression
fracture and requiring surgical intervention.1,2 In addition, this patient was very obese (98 kg) and had a very
unstable cardiac status. Successful surgical management
for this patient has prompted us to write this case report.
Aim: To report an unusual case concomitant osteoporotic
compressed thoracic fracture with lumbar spondylolisthesis
and severe comorbidity.
Case: A 68 years old female complaining 3 months severe
low back pain and right thigh pain after falling on the floor. On
physical examination, she had bilateral foot drop, there was no
sensory loss and neither any bowel and bladder involvement
with cardiovascular problem 70% left artery coronary obstruction on cardiac angiography.
Investigation: Magnetic resonance imaging (MRI) D12 compression fracture with spinal cord and thecal sac compression
and spondylolisthesis L5-S1.
Management: L5 laminectomy, L4/5 and S1 posterior stabilization, D-12 laminectomy and transpedicular vertebroplasty and
posterior stabilization of D11-L1.
Result: The pain was significantly reduced after the surgery.
Conclusion: Open surgery among osteoporotic compression
fracture in thoracic spine and degenerative spondylolisthesis
in lumbar spine needs further evaluation regarding comorbid
disease which often present in advancing age.
Keywords: Compression fracture, Spondylolisthesis, Vertebroplasty, Laminectomy and posterior stabilization.
How to cite this article: Pawar SG, Ramani P, Ibrahim IS.
Major Spinal Surgery Procedure on a High Cardiovascular
Risk Patient with Symptomatic Neural Compression due to 1:
Osteoporotic T12 Compression Fracture along with 2—L5/S1
Spondylolisthesis. J Spinal Surg 2014;1(3):138-140.
Source of support: Nil
Conflict of interest: None
1
DNB Resident, 2Senior Consultant, 3Neurosurgeon
1,2
Department of Neuro Spinal Surgery, Lilavati Hospital and
Research Centre, Mumbai, Maharashtra, India
3
Department of Neuro Spinal surgery, Utara Adam Malik
Hospital, University of Sumatera, Medan, Indonesia
Corresponding Author: Sumeet G Pawar, DNB Neurosurgery
Resident, Department of Neuro Spinal Surgery, Lilavati
Hospital and Research Centre, Mumbai, Maharashtra, India
Phone: 02226417001, e-mail: [email protected]
138
Case report
A 68 years old obese (98 kg) patient had complained of
chronic low back pain for several years with neurogenic
claudication. She had preferred conservative treatment
until recently (3 months back) when she fell down in the
house and sustained injury to the back. She complained
of severe pain in the upper back and right sciatica making
her life miserable and she was now asking for surgical
treatment.
Clinically, her right SLR was restricted. Both ankle and
right knee jerks were absent. She had developed bilateral
foot drop with 0/5 power in left foot and 1/5 in right foot.
Locally, there was kyphus prominence in the DL region
of spine and it was tender. She also had tenderness in the
lumbosacral region. She also had gross osteoarthritis in
both knees being more marked in left knee joint.
Investigations
X-rays and magnetic resonance imaging (MRI) done
showed that she had T12 compre­ssion fracture causing
kyphotic deformity and severe compression of the spinal
cord at that level.
She also had L5/S1 spondylolisthesis with severe
lateral recess stenosis at L5/S1 and L4/5 levels (Figs 1A
to C).
She required decompression and correction of
kyphotic deformity in the DL region as well as surgical
correcton of L5/S1 spondylolisthesis.
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Major Spinal Surgery Procedure on a High Cardiovascular Risk Patient with Symptomatic Neural Compression
A
B
C
Figs 1A to C: (A) Lateral thoracolumbar X-ray showing T12 compression fracture, (B and C) MRI T2 sagittal and axial section
showing T12 compression fracture with spinal cord and thecal sac compression with spondylolisthesis L5-S1
She suffered from high blood pressure and uncontrolled diabetes for more than 10 years with fasting blood
sugar of 600 mg/dl, and has been under the treatment of
cardiologist for poor functioning of the heart. Her ECG
showed old anteroseptal infarct. The ejection fraction
(EF) was 35%. On admission, the cardiologist felt that
her heart condition needed to be stabilized before under­
taking surgery as she had NT proBNP of 5336 mg/dl
indicative of congestive heart failure and, hence, she was
discharged and readmitted after 3 weeks with heart
stabilized with medicines. The cardiologist agreed for her
to undergo back surgery first in view of severe pain but
she remained a high-risk patient. The fact was explained
to the relatives, and surgery was undertaken with the
consent of the relatives.
The surgery was undertaken with cardiologist
standby, arterial monitoring and central venous line in
the right jugular vein for any eventualities.
The surgery, a double PLIF procedure lasting 8 hours,
was conducted smoothly with anesthetist maintaining
adequate blood pressure, stable cardiac status and satisfactory respiratory end-tidal volume.
surgical procedure
This was done in two stages. In the first stage, D12 laminectomy was done with bilateral internal decompression
of spinal stenosis (IDSS) to decompress the cord. Vertebroplasty was done and, although preoperative X-rays
showed significant collapse of vertebra with two endplates almost touching each other, almost 80% expansion
was achieved with good planum obtained in the anterior
and superior endplates. Patient being obese, further stabi­
lization of the segment was done with pedicle screw in
T11 and L1. In stage 2, the lower lumbar spine and the
sacrum was stabilized with dynamic screws following
decompression (Figs 2A and B).
The Journal of Spinal Surgery, July-September 2014;1(3):138-140
A
B
Figs 2A and B: Postoperative dorsolumbar X-ray showing
pedicle screw on T11 and L1 with PMMA filling the T12
vertebral body and L4, L5 and S1 pedicle screw fixation
Her postoperative period was most uneventful, and
she had stood the procedure well but she was transferred
to ICU in view of her unstable heart and was observed
there for 24 hours before transfer to the room. She was
quickly mobilized and made to walk with support but
the walking was hindered because of two factors namely,
bila­teral foot drop and osteoarthritis of knee joints. She
was discharged from the hospital after 5 days with
instructions to continue physiotherapy with electrical
stimulation and splints for both feet, and further ins­tru­c­tions for controlling diabetes, blood pressure and supervision over unstable ischemic heart.
She was seen for follow-up of 2 weeks and she has
been progressing satisfactorily. She was brought on a
wheel chair and was comfortable although at first admi­s­sion she came on a strecher. The postoperative X-rays
show satisfactory decompression of dural sac at both
places and satisfactory stabilization of the spine in both
regions. She could sit comfortably and had no pain.
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Sumeet G Pawar et al
Discussion
The impact of osteoporosis is increasingly recognized
in the aging population. Vertebral compression fractures are a significant problem associated with pain
and functional impairment. Traditional, open surgery
has been problematic in the management of patients in
this population because of poor bone quality, frequent
and extensive medical comorbidity, and the overall
frail patient condition. Recent studies are trying to
establish methods to access bone quality intraoperatively.3
Nonoperative management, including medications for
pain relief and bracing, has been used traditionally;
however, many patients are left with incapacitating
residual pain and are unable to return to their previous
level of activity.
While the option of conservative management seems
to be better in patient with high cardiac risk and other
comorbidities, the overall outcome is always better with
surgical intervention. As seen in our patient, the cardiac
risk was very high due to postinfarct status of the heart,
poor ejection fraction and congestive cardiac failure. Due
to osteoporotic compression fracture and severe low back
pain from spondylolisthesis, the patient was bed ridden
for more than 3 months and she wanted a surgery to
improve her mobility. Hence, operative management was
planned for her and she stood the procedure well, and
was quickly mobilized much to her satisfaction. However,
her joy could not be complete due to severe osteoarthritis
in the knee joints and bilateral foot drop.
Vertebroplasty is effective in reducing pain and acce­
lerating patient’s functional status. In our patient, the
expansion of the vertebral body was extremely satisfactory with good planum maintained anteriorly, superiorly
and inferiorly. Vertebroplasty and/or kyphoplasty have
been proven to be a significant advancement in the treatment of patient with steoporotic compresion fractures.4,5
Addition of adjacent vertebrae with pedicle screws and
rods provides 360º stability in an obese patient with
unstable segment in the DL region which had already
caused segmental kyphosis.
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Osteoporotic compression fracture and degenerative
spondylolisthesis patients are usually in advanced age
and often present with several comorbidities like our
patient who had diabetes, blood pressure, ischemic heart
disease, poor cardiac status and severe obesity. Patients
with symptomatic spondylolisthesis like our patient
who undergoes decompression and posterior lumbar
interbody fusion are reported to have reduced pain
and have a better functional outcome6 due to mobility
possible because of operative procedure in patients who
are otherwise bed ridden like our patient who was bed
ridden for more than 3 months.
Conclusion
Providing mobility to patients who are bed ridden with
severe low back pain from spondylolisthesis and severe
pain in the DL region from osteoporotic fractures is a
blessing for the elderly patients even by taking risk with
the associated comorbid conditions.
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feasibility study. Spine J Online Publication; 2013 Aug 1.
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