453 - From Fusion To Fracture: A Case Report

Friday, February 23, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

SG

Simron Gill, MD

Resident Physician
SUNY Downstate Health Sciences Center
New york, New York, United States

Co-Author(s)

MR

Marc Ramos Emos, MD

Resident Physician
SUNY Downstate Health Sciences University
BROOKLYN, New York, United States
AP

Anam Purewal, MD

Resident Physician
SUNY Downstate Health Sciences University
Brooklyn, New York, United States
JD

Jason Do, DO

Resident Physician
SUNY Downstate
Brooklyn, New York, United States
JM

Jack Mensch, MD

Attending Physician
Staten Island University Hospital
Staten Island, New York, United States
Sanjeev Agarwal, MD

Chief of Service & Residency Program Director
SUNY Downstate Health Sciences University
Brooklyn, New York, United States

Case Diagnosis: Atypical L5 Compression Fracture

Case Description: A 71-year-old female known for hypertension initially consulted her primary care physician due to progressively worsening lower back pain over a decade. The pain radiated down her left leg, impeding mobility. An outpatient MRI unveiled degenerative disc disease with grade 2 spondylolisthesis at the L4-L5 level. Consequently, she underwent elective L4-L5 laminectomy instrumentation and fusion, alongside a left L3 to L4 microdiscectomy. Post-surgery, ambulation improved, and pain was manageable with opioids. Nevertheless, she returned to the hospital four weeks later reporting persistent lower back pain despite medication and home therapy. Imaging of her lumbar spine uncovered a fresh compression fracture of the L5 vertebral body, with the left-sided L5 pedicle screw extending beyond the vertebral body. Subsequently, she underwent L3-S1 fusion revision, removal of the L5 screw, and placement of pedicle screws from L3-S1. After completing acute rehabilitation, she was discharged home with overall improved pain management and ambulation.

Discussions: Decompressive laminectomy with or without fusion is a common procedure for chronic lower back pain attributed to spinal stenosis and symptomatic spondylolisthesis. Post-operative fracture risk is elevated in the first six to 12 months, especially in patients with underlying osteoporosis. The choice of screws plays a role in fracture prevention, with cortical screws being less likely to cause fractures at insertion sites. This patient had no history of osteoporosis, recently had a normal bone mineral density scan, and reported no trauma or falls.

Conclusions: The risk of vertebral fractures following spinal surgery hinges on factors such as patient age, osteoporosis, the number of fused levels, and sacral involvement. In cases of persistent post-surgical back pain with no improvement in the initial weeks, the possibility of fractures related to instrumentation should be considered.