2021 Volume 12 Issue 6 Pages 898-902
The patient was 69-year-old man who had several previous spinal surgeries in other hospitals: L4-L5 lumbar disc herniation at 26 years of age; C4-C5 and C5-C6 anterior decompression and fusion at 45 years of age; L4-L5 decompression surgery at 46 years of age; and T11-L5 posterior fusion with L3-L4 posterior lumbar interbody fusion surgery at 63 years of age. He visited the first author's hospital because of recently developed walking discomfort 6 years after the last surgery. One year after the index visit, he was admitted for the progression of intermittent claudication and unstable walking. Physical examination showed slight weakness of muscle strength (level 4 on manual muscle testing) in the lower extremities and sensory disturbance below the T11 level without any abnormality of the deep tendon reflexes. Radiography showed a right-convex long thoracolumbar scoliosis with a Cobb angle of 27 degrees and loosening of pedicle screws in the T11 and T12 vertebrae. Computed tomography showed a right-sided parallel shift of loosened T11 pedicle screws and destruction of the inner wall of the spinal canal by the left screw. Severe compression of the spinal cord was observed on myelography and magnetic resonance imaging. Surgery was performed for removal of the T11 and T12 pedicle screws and proximal extension of thoracolumbar fixation up to the T7 vertebra, with special attention to avoid spinal cord injury during screw removal. After surgery, the patient recovered rapidly and was capable of walking more than 5 km cane-free without claudication or staggering one year after surgery.
Many complications at proximal instrumented vertebrae in patients undergoing long thoracolumbar spinal fusion surgery have been reported as the proximal junctional failure (PJF) or kyphosis (PJK). Though the majority of previous reports regarding PJF and PJK presented problems related to sagittal alignment, few reports have described pain and fractures related to the coronal alignment. In the present case, myelopathy with spinal canal destruction was caused by repeated lateral bending to maintain the straight standing position. This type of complication at the proximal instrumented vertebrae is relatively rare but important to avoid the development of myelopathy. Therefore, correction of the coronal alignment, as well as the sagittal alignment, at the lower lumbar and/or lumbosacral region and extended upward fixation above the T9 vertebra should be considered in the initial spinal surgery.
