AUCTORES
Globalize your Research
case report | DOI: https://doi.org/10.31579/2692-9392/136
1 Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P.R. China.
*Corresponding Author: Jiancheng Zeng, Department of Orthopedics and Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P.R. China.
Citation: Long Zhao, Xiandi Wang, Tianhang Xie, Jiancheng Zeng, (2022) Vertebrae Coronal Fracture following Oblique lateral Lumbar Interbody Fusion: Case Report. J. Archives of Medical Case Reports and Case Study, 6(4); DOI:10.31579/2692-9392/136
Copyright: © 2022 Jiancheng Zeng, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 30 June 2022 | Accepted: 07 July 2022 | Published: 22 September 2022
Keywords: vertebrae coronal fracture (vcf); oblique lateral lumbar interbody fusion (olif); anterolateral fixation; osteoporosis
Objective: Oblique lateral lumbar interbody fusion (OLIF) surgery has been increasingly proposed a preferred minimally invasive approach for lumbar degenerative pathology. We aimed to report cases with vertebrae coronal fracture (VCF) following OLIF combined with anterolateral single-rod screw fixation (OLIF-AF).
Methods: A retrospective review was performed on all patients who underwent minimally invasive OLIF-AF surgery between October, 2017 and February, 2021. Patients with VCF were selected for further analysis.
RESULTS: Two patients (0.37%) out of 534 total patients (707 levels) were identified with VCF following OLIF-AF. Both patients presented with severe back pain and radiating to bilateral legs within 10 days after surgery. Both patients were osteoporosis and had improper lumbar motion at early stage postoperative. Managed with conservative treatment, the VCF healed and successful interbody fusion were achieved in both patients.
CONCLUSIONS: VCF following OLIF-AF surgery is a rare but anguished complication. The contributing factor may include osteoporosis, overweight and premature improper lumbar motion. Based on these fracture reports, we caution surgeons should repeatedly advise patients to limit lumbar movement at early stage postoperative, especially for osteoporosis patients.
fusion (OLIF) surgery has been recently popularized for patients with lumbar degenerative pathology [1-3]. With the increasing number of OLIF surgery being performed, the related known complications profile have been initially reported including cage subsidence, vascular and nerve injury, endplate violation, ureteral injury, ileus, peritoneal tear and so on [4-6].
As a serious complication, the vertebral coronal fracture (VCF), which was associated with severe pain, mobility disability and even reoperation, following lumbar interbody fusion surgery have been sporadically reported in the direct lateral approach, with the incidence of 0.6%-15.4%, which varied with different instrumentation usage [7-9]. However, to our knowledge, the VCF following OLIF surgery have not yet been mentioned in the previous literature. In this report, we were committed to present with 2 cases with the VCF among the total of 534 patients who underwent OLIF surgery combined with anterolateral fixation (OLIF-AF), which performed by a single senior surgeon between October, 2017 and February, 2021 in our institution.
Report of the case
Case Ⅰ
A 76-year-old female visited our clinic with the complaint of chronic low back pain for 30 years and aggravated with right leg numbness for 4 months. A physical examination showed that numbness was found on the right posterior thigh and lateral calf, and ankle dorsal extensor muscle strength decreased. Dynamic instability was observed at X-ray (Figure 1a), and the MRI demonstrated that disc bulge causing spinal stenosis at L4-5 (Figure 1b). Prior to admission, she insisted on treating her tetter with corticosteroids more than 10 years, and the admission assessment revealed osteoporosis (T score= -2.7), and the body mass index (BMI) was 23.9 kg/m². After experienced failure conservative treatments for lumbar and leg pain, she finally underwent OLIF-AF surgery. Postoperative radiological examinations showed no endplate violation occurred intraoperatively and the disk space was clearly distracted (Figure 1c). Subsequently, the patient was discharged home on 2 days postoperatively with resolution of preoperative complaint.
Just 7 days postoperatively, following an unconscious excessive lumbar bending, a sharp pain was aroused in her lower back and radiated to bilateral legs. Emergency 3D-CT showed a coronal fracture of the L4 vertebrae, with the anterior half of the fractured vertebra slightly displaced upwards and forwards. The fracture line originated from the contact plane between the cage posterior upper edge and the vertebrae (Figure 1d). Treatment options were given and the patient chose conservative treatment including analgesics, anti-osteoporosis, strict bed rest, and then began to gently walk under the brace after acute phase. Three months postoperatively, the pain was clearly relieved, and the 3D-CT examination revealed the osteotylus connection formation. The 3D-CT examination taken at 12 months postoperatively showed the vertebrae fracture healed and the successful fusion was also achieved (Figure 1e). The pain was mostly relieved, even so, anti-osteoporosis was recommended to be insisted on.
Figure 1. (a), preoperative dynamic X-ray radiographs revealed instability at L4-5; (b), preoperative MRI revealed spinal canal stenosis at L4-5; (c), 3D-CT taken at 1day postoperative revealed good positioning of cage within the disc space without evidence of endplate violation or cage subsidence; (d), emergency 3D-CT (7 days postoperatively) revealed coronal fracture of the L4 vertebrae, with the cage counterclockwise rotation; (e), 3D-CT taken at 12 months postoperatively revealed the vertebrae fracture healed and the successful fusion was also achieved.
Case Ⅱ
A 60-year-old female visited our clinic with the presence of repeated low back pain for 3 years, which aggravated with intermittent claudication for 6 months. She was neurological deficit on physical examination with numbness at the left lateral calf and instep, and the thumb dorsal extensor strength decreased. She also presented with some past medical histories included diabetes, hypertensive disease, and Cushing's syndrome more than 15 years. The admission assessment revealed severe osteoporosis (T score= -4.0), and normal BMI (23.1kg/m²). The radiological examinations showed a grade Ⅱ degenerative spondylolisthesis of L4 (Figure 2a), and spinal canal stenosis at L4-5 level (Figure 2b). After failing non-operative management, she eventually underwent an uncomplicated OLIF-AF surgery. Postoperative radiological examination revealed the spondylolisthesis of L4 was certainly corrected without endplate violation (Figure 2c), and a clearly spinal canal expansion was achieved (Figure 2d). Routinely, the patient was discharged home on 2 days postoperatively with the pain relived.
Exactly 10 days postoperatively, after undergoing a negligent lumbar bending and twisting, the patient immediately experienced severe pain in lower back, which meanwhile radiating to bilateral legs. Emergency 3D-CT examination confirmed that a non-displacement coronal fracture of the L5 vertebrae and cage subsided into the fractured vertebrae (Figure 2e). Refused re-operation, the patient chose conservative treatment included analgesics, anti-osteoporosis, strict bed rest, and then gradually softly walked under the brace after 6 weeks. Three months postoperatively, 3D-CT showed that the osteotylus connection formation and no visible progress in cage subsidence. The pain was distinctly relived and the patients was allowed moderately walk under the brace protect. The 3D-CT examination taken at 12 months postoperatively showed the vertebrae fracture line disappeared (Figure 2f). Although the pain was almost relieved, anti-osteoporosis was still recommended to be insisted from now on.
Figure 2: (a), preoperative X-ray radiographs revealed Ⅱ° spondylolisthesis of L4; (b), preoperative MRI revealed spinal canal stenosis at L4-5; (c), 1day postoperative 3D-CT revealed good positioning of cage within the disc space without evidence of endplate violation or cage subsidence; (d), 1day postoperative MRI revealed clearly expansion of the spinal canal; (e), emergency 3D-CT (10 days postoperatively) revealed a non-displacement coronal fracture of the L5 vertebrae and cage subsided into the fractured vertebrae; (f), 12 months postoperatively, the 3D-CT revealed the vertebrae fracture healed and the successful fusion was also achieved.
In our series of 534 patients with 707 levels who underwent OLIF-AF surgery, two patients experienced VCF at the operated level, with an extreme lower incidence which accounting for 0.4 % of total operated patients, or 0.3 % of total operated levels. This rate was almost agreement with the report of VCF following lateral lumbar interbody fusion (LLIF) surgery in previous large cohort. Rodgers et al. [7] reported the vertebrae fracture rate of 0.7 % among 600 patients who underwent LLIF surgery, and eventually caused reoperation. Subsequently, Tempel et al. [8] reported that among a total of 335 patients with 712 levels who underwent LLIF stand-alone surgery, 2 female suffered vertebrae fractures within 2 weeks postoperatively, with the incidence of 0.6% of patients, or 0.3 % of total operated levels. Additionally, in a small cohort, Dua et al. [9] reported a late vertebrae fracture with the incidence of 15.4 % in a group of 13 patients who underwent LLIF surgery with supplemental lateral plate and unilateral pedicle screw instrumentation.
Causes for VCF following lumbar interbody fusion surgery tends to be multifactorial. The intrinsic biomechanical properties of the construct may be a potential factor should be responsible for the VCF [8]. As shown in the biomechanical study performed by Fogel et al. [10], the construct of interbody cage combined with anterolateral instrumentation presented with a higher range of motion in the sagittal plane compared to that in the construct of interbody cage combined bilateral posterior pedicle screw instrumentation. In our study, both patients immediately suffered VCF following an inappropriate lumbar movement in sagittal plane. The emergency 3D-CT of the first fractured patient showed that the cage anterior lower edge was subsided into the L5 vertebrae, and the cage posterior upper edge was incised into the L4 vertebral body and then derived a fracture line in the coronal plane, which indicated that the cage may roll in the disc space and then cut the L4 vertebra. We speculated that the sufficient stability could not be provided by the anterolateral instrumentation during the lumbar spine excessively rotated in the sagittal plane, thus causing the cage rolled in the disk space and cut the vertebrae. Moreover, the cage anteroposterior diameter was also suspected as a factor affecting its stability in the disk space. A smaller anteroposterior diameter cage was not believed to provide sufficient drag torque to limit the cage rolled in the disc space [11]. The two fractured patients in our study were both implanted a cage with higher height (14mm) but narrow width (18mm), which more likely to lead to rolled in disc space and then cut the vertebrae.
Both patients discussed in this report were presented with osteoporosis, which caused by the additional medical comorbidities which associated with “corticosteroid overdose”. Bone mineral density (BMD) was considered to be a vital factor affecting the fate of instrumentation in lumbar fusion surgery. Previous study have confirmed that the impaired BMD were associated with the implant subsidence, migration, and screw loosen, pulling out, even cleavage vertebrae [6, 12-14]. In our study, two patients presented with osteoporosis. The emergency 3D-CT showed that the relative location of the screw within the fractured vertebrae was clearly descended, and cross the fracture line. This result indicated that the osteoporotic condition was unable to resist screw cuts and then be the cause of coronal fracture. In addition, we noticed that the two fractured patients were female. This appearance was coincided with the report by Tempel et al. [8]. The sex specificity may be explained by that the curvature of lumbar lordosis increases more in females than in males and with age which may result in increased interfacial loading between the cage and endplate. Moreover, an increased incidence of osteoporosis in postmenopausal status in females compared to males also may responsible for this result [15-16].
Management of VCF after lumbar fusion surgery varied from conservative to extensive posterior bilateral pedicle screw instrumentation. However, some complication may arise during the reoperation. Tender et al. [11] reported a case of a deep wound infection following posterior revision for VCF. In our study, the two patients both chose the conservative treatment including analgesics, anti-osteoporosis and strict bed rest. Eventually, the fracture healed and successful fusion was achieved.
VCF following OLIF-AF surgery is a rare but anguished complication. The contributing factor may include osteoporosis, overweight and premature improper lumbar motion. Based on these fracture reports, we caution surgeons should repeatedly advise patients to limit lumbar movement at early stage postoperative, especially for osteoporosis patients.
Statements
Comprehensive agreement for academic use of information was obtained from the patients and no identifiable information of the participants was included in the manuscript.
Acknowledgments: We would like to thank AJE (www.aje.com) for English language editing.
Competing interests: The authors have no conflicts of interest to declare
Funding: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Consent for publication: Not applicable
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
