Posterior Transcanal Lumbar Interbody Fusion for Septic Vertebral Fracture Pseudarthrosis and Sitting Imbalance

Abstract

Case report. To describe a new method to treat septic pseudarthrosis of the lumbar spine via a transcanal approach. Septic pseudarthrosis of the spine after multiple unsuccessful anterior and posterior surgeries for vertebral fracture represents a challenge for spine surgeons. Septic pseudarthrosis associated with dorsal fistula developed in a 40-year-old paraplegic man after unsuccessful combined anterior and posterior instrumentation for L3-burst fracture and sagittal sitting imbalance caused by collapsing spine. The instrumentation was removed together with meticulous pseudarthrosis debridement, fistula excision, and intravenous antibiotics plus continuous irrigation. Three months later, the pseudarthrosis area was approached via a posterior transcanal route because of the preceding multiple anterior transperitoneal and retroperitoneal surgeries. Posterior interbody instrumentation and fusion were performed with titanium mesh cages filled with autologous iliac bone graft. Pedicle screw-rod instrumentation was additionally applied to reinforce the interbody fusion and restore lumbar lordosis. Following this operation, the patient was ambulated with a custom made plastic jacket in his wheelchair. The postoperative course was uneventful, and the patient regained his sitting ability progressively. Four months later, the blood count analysis was within normal limits. Radiologically, there was a complete fusion at the level of instrumentation, while the preoperative lost lumbar lordosis was sufficiently restored. The patient was reemployed 6 months after surgery in his previous work in a sitting position, and, during the last observation 4 years later, he had normal labor analysis and lumbar lordosis. This extremely rare case focuses on the use of the transcanal approach to treat adequately lumbar septic pseudarthrosis and restore lumbar lordosis in definitively paraplegic patients in whom no anterior approach can be used.