Progressive Low Back Pain Research Articles

Spinal epidural lipomatosis (SEL).

We present a case of an 87-year-old man with spinal epidural lipomatosis (SEL). The patient had been diagnosed with microscopic polyangiitis and treated with prednisone at a 5mg daily dose. He has a 1-week history of progressive low back pain radiating to the posterior of the right thigh. A spinal magnetic resonance imaging scan revealed SEL in L2-L4. SEL is a rare condition with adipose tissue accumulation in the spinal canal's epidural space, leading to spinal cord or nerve root compression. The greatest risk of SEL is corticosteroid use, and corticosteroid reduction may improve the disease. Physicians should list SEL in the differential diagnosis if a patient on corticosteroid therapy presents with back pain and acute cauda equina symptoms.

High-Grade Staphylococcus lugdunensis Bacteremia in a Patient on Home Hemodialysis.

Staphylococcus lugdunensis (S lugdunensis) is a species of coagulase-negative Staphylococcus and a constituent of human skin flora. S lugdunensis has gained notoriety for its virulence, which resembles Staphylococcus aureus (S aureus). S lugdunensis is now recognized as an important nosocomial pathogen and cause of prosthetic device infections, including vascular catheter infections. A 60-year-old man with a history of uncontrolled type 2 diabetes mellitus and end-stage renal disease on home hemodialysis via arteriovenous fistula (AVF) presented to the emergency department for evaluation of subacute progressive low back pain. Initial laboratory tests were notable for elevated inflammatory markers. Magnetic resonance imaging with contrast of the thoracic and lumbar spine revealed abnormal marrow edema in the T11-T12 vertebrae with abnormal fluid signal in the T11-T12 disc space. Cultures grew methicillin-sensitive S lugdunensis. The patient's antibiotic regimen was narrowed to IV oxacillin. He was transitioned to IV cefazolin dosed 3 times weekly after hemodialysis and an outpatient dialysis center. Treatment of bacteremia caused by S lugdunensis or S aureus should be managed with prompt initiation of IV antistaphylococcal therapy, a thorough evaluation for the source of bacteremia as well as metastatic complications, and consultation with an infectious disease specialist. This case highlights AVF as a potential source for infection even without localized signs of infection. The buttonhole method of AVF cannulation was thought to be a major contributor to the development and persistence of our patient's bacteremia. This risk should be discussed with patients using a shared decision-making approach when developing a dialysis treatment plan.

Isolated cryptococcal osteomyelitis of the sacrum in an immunocompetent patient: a case report and literature review

BackgroundCryptococcus neoformans, an opportunistic fungal pathogen, seldom causes infection in immunocompetent people. Cryptococcal osteomyelitis is an uncommon condition in which Cryptococcus invades the bone. It usually occurs as part of a disseminated infection and rarely in isolation. The spine has been reported as the most common site of cryptococcal osteomyelitis; however, isolated case of sacrum involvement in immunocompetent patients has never been reported.Case presentationWe report the case of a 37-year-old man without underlying disease who presented with progressive low back and sacrococcygeal pain. The patient was initially diagnosed with sacral tumour by a local doctor, and subsequently, after admission, was diagnosed with sacral tuberculosis. He was empirically treated with antitubercular drugs. The patient failed to respond to antitubercular drugs and complained of worsening low back pain. Additionally, he developed persistent radiating pain and numbness in his legs. For further diagnosis, we performed a computed tomography-guided puncture biopsy of the sacrum, which revealed granulomatous inflammation with massive macrophage infiltration and special staining revealed a fungal infection. We performed sacral debridement and drainage and obtained purulent specimens for pathological examination and microbial culture. Microbial identification and drug susceptibility tests revealed a Cryptococcus neoformans infection sensitive to fluconazole. Postoperatively, the persistent radiating pain and numbness in the legs resolved. After 12 consecutive weeks of antifungal therapy, all his symptoms resolved. The patient remained without any signs of recurrence at the 8-month follow-up.ConclusionWe reported a rare case of isolated sacrum cryptococcal osteomyelitis in an immunocompetent patient. Furthermore, we identified and reviewed 18 published cases of spine cryptococcal osteomyelitis. Immunocompetent individuals are also at risk for cryptococcal osteomyelitis. Clinical manifestation and imaging are insufficient to diagnose cryptococcal osteomyelitis of the spine, and invasive examinations, such as puncture biopsy and fungal examinations, are needed. Antifungal therapy yields satisfactory results for the treatment of cryptococcal osteomyelitis of the spine, however, if the infective lesion is large, especially when it compresses the spinal cord and nerves, a regimen combining aggressive surgery with antifungal therapy is indispensable.

Conservative Management of Cauda Equina Syndrome: A Case Report

BACKGROUND: Cauda equina syndrome (CES) treatment usually involves immediate consultation for surgical management. CASE PRESENTATION: We report the case of a 64-year-old woman exhibiting a 6-monthold progressive low back pain associated with motor weakness (right psoas and quadriceps), hyporeflexia (right patellar, left hamstring, and bilateral Achilles tendons) hypoesthesia on the L2-3 dermatome, and sexual and bowel dysfunction. The patient was referred for a neurosurgical consultation. Surgery was not considered at this time, and the patient was referred to the universitybased chiropractic clinic. OUTCOME AND FOLLOW-UP: After 22 treatments, the patient reported a self-perceived percentage of improvement of 80%, a verbal numeric pain-rating scale at 2/10 and a 22% Oswestry score. Her bowel dysfunction, sexual dysfunction, and perineal numbness were resolved. DISCUSSION: We aim to work in collaboration with surgical teams to conduct shared decisionmaking with patients and offer conservative care for CES if deemed safe and appropriate. Future research should contribute to the identification of CES cases that might benefit from conservative care when surgery is not considered an immediate option. JOSPT Cases 2022;2(4):189–195. Epub: 12 October 2022. doi:10.2519/josptcases.2022.10946

Single-Position Anterior and Lateral Lumbar Fusion in the Supine Position: A Novel Technique for Multilevel Arthrodesis

Anterior lumbar interbody fusion (ALIF) and lateral lumbar interbody fusion are common techniques that typically require staged procedures when performed in combination. Interest is emerging in single-position surgery to increase operative efficiency. We report a novel surgical technique, supine extended reach lateral fusion, to perform ALIF and lateral lumbar interbody fusion with the patient in a single supine position. A man in his fifties presented with degenerative levoscoliosis, spondylolisthesis, sagittal plane deformity, and progressive low back pain. He was offered L3-S1 anterolateral fusion. With the patient supine, a left abdominal paramedian incision was performed to gain anterior retroperitoneal access, and standard L5-S1 and L4-5 ALIFs were performed. The anterior incision was used for direct visualization, retraction, and bimanual dissection. A left lateral incision was then made to perform an L3-4 lateral lumbar interbody fusion. He subsequently underwent a second-stage L3-S1 posterior percutaneous fixation. The patient tolerated the procedures well, without complications. His postoperative radiograph findings confirmed acceptable implant positioning. He was discharged home in stable condition and was doing well at follow-up. This case description is the first report of the supine extended reach technique, which allows incorporation of anterior and lateral fusion constructs at adjacent levels without changing patient positioning. Many surgeons believe the ALIF to be the most powerful technique for achieving lordosis, and this technique enables concomitant lateral access in a supine position. It can also be used as an alternative strategy when anterior access to the disc space is unobtainable. Further clinical investigation of this technique is warranted.

Paraganglioma of the Spine: Review of 6 Cases in 20 Years at a Single Institution

Paragangliomas are rare neuroendocrine tumors that may localize to the spine causing progressive low back pain variably accompanied by radiculopathy. Recurrence, follow-up duration, and role of adjuvant therapy remain unestablished. We interrogated our institution's histopathology database for all confirmed cases of spinal paraganglioma between 2000 and 2021. Patient records were retrospectively reviewed to extract diagnostic features, operative treatment, and follow-up outcomes. 6 cases of spinal paraganglioma were surgically treated (67% female vs. 33% male, mean age= 51.3years). Preoperative symptom duration did not correlate with tumor size (Spearman r=0.154, P=0.80). The mean postoperative follow-up duration lasted 3.3years (range= 2-96months). There were an equal number of primary and metastatic lesions. 1 tumor exhibited secretory features and was consequently embolized preoperatively. No residual or recurrent disease was evident in the primary cases; however, 2 metastatic cases recurred within 2years of surgery and 1 patient died. Given nonspecific clinical and radiologic features, spinal paragangliomas are diagnosed via biopsy or after surgery. Complete surgical resection is often necessary to alleviate symptoms and prevent tumor recurrence. In cases with benign metastases, long-term surveillance is important and adjuvant medical and radiotherapeutic treatment may be beneficial.

Primary intra- and extradural extramedullary mesenchymal chondrosarcoma with isolated punctate calcification: case report and literature review

BackgroundMesenchymal chondrosarcoma (MCS) is an ultra-rare, high-grade subtype of chondrosarcoma affecting both bone and soft tissues. Extra-skeletal MCS rarely occurs in intra- and extradural regions.Case presentationWe presented a case of intraspinal dumbbell-shaped MCS at the T12-L2 level with isolated punctate calcification in a 19-year-old male complaining of progressive lower back pain. Surgical treatment for removal of the tumor was performed. The postoperative pathological result confirmed MCS. The patient showed symptomatic improvement and follow-up MRI showed no evidence of recurrence or metastasis for nearly 1 year after surgery.ConclusionsCT and MRI play an important role in differential diagnosis for intraspinal MCS. MCS should be added to the differential diagnosis of intraspinal dumbbell-shaped tumors, especially when radiological examinations reveal punctate calcification in a homogeneous enhanced tumor without dural tail sign. However, the final diagnosis depends on histopathological results. Despite the good prognosis of intraspinal MCS, close follow-up after operation is still necessary.

Tumor-Induced Osteomalacia With Normal Fibroblast Growth Factor-23 (FGF23) and Idiopathic Hypercalciuria

Tumor-induced osteomalacia (TIO) is a rare acquired paraneoplastic syndrome characterized by low serum phosphate, phosphaturia, inappropriately low/normal levels of serum calcitriol, and normal or elevated levels of fibroblast growth factor-23 (FGF23). Finding this mesenchymal tumor is challenging since it is usually benign, small, slow-growing, and is localized in the appendicular skeleton. We report a 58-year-old male patient who arrived at the endocrinology outpatient clinic due to slowly progressive low back pain and generalized weakness since the age of 48. On physical examination, only a reduced range of motion was noted. Laboratory tests revealed hypophosphatemia with normal parathyroid hormone (PTH) levels, normal serum calcium, high 24-hour urine calcium, normal 1,25-dihydroxyvitaminD levels, low renal threshold phosphate concentration (TmPO4/GFR), and high FGF23. The 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) reported a hypermetabolic extramedullary lesion in the C1-C2 vertebral bodies measuring 1.5 x 1.1 cm. Two months after the 18F-FDG PET/CT, complete excision of the cervical tumor was performed. The pathology ward reported a histiocytic mesenchymal neoplasm with accumulations of multinucleated giant cells compatible with phosphaturic mesenchymal tumor. After surgery, the patient’s hypophosphatemia was completely resolved. With this, the diagnosis of TIO was confirmed. The patient remains asymptomatic, with normal phosphate levels at one year of follow-up. Hypophosphatemia due to renal losses in an adult patient is a challenging diagnosis and one must consider TIO, autosomal dominant hypophosphatemic rickets, fibrous dysplasia, and even Fanconi syndrome. FGF23 can be extremely useful during the diagnostic approach since acquired dependent hypophosphatemia (FGF23 ≥ 30 RU/mL) highly suggests TIO. In this case report, we want to highlight the paramount importance of adequate tumor screening in adult patients with acquired FGF23-dependent hypophosphatemia. TIO is a reversible cause of hypophosphatemia with potentially disabling consequences if left untreated. These manifestations are non-specific (bone pain and muscle weakness), while others are progressive and severely disabling (bone deformities and multiple fractures). In this case report, we want to highlight the paramount importance of adequate tumor screening in adult patients with acquired hypophosphatemia, and the crucial lead that phosphate and vitamin D regulating hormones (FGF23) have for suspecting TIO.

Progressive Lower Back Pain With New-Onset Symptoms

This is a case study describing a young woman with a chief complaint of low back pain (LBP) symptoms. Initially, she was evaluated and treated for LBP. Her back pain worsened over the course of 16 weeks, and she eventually developed chills and fever. Knowledge of the presentation, assessment, and differentials in patients with LBP is essential to quickly identifying, diagnosing, treating, and referring patients with uncommon etiologies.

Ten-Step Minimally Invasive Treatment of Lumbar Giant Disc Herniation via Unilateral Tubular Laminotomy for Bilateral Decompression: 2-Dimensional Operative Video.

Giant disc herniation (GDH) is generally defined as a lumbar disc herniation that obstructs 50% or more of the space in the spinal canal.1-3 Common treatment options for GDH include unilateral interlaminar approach, bilateral approach, or open full laminectomy.4,5 Surgical treatment of GDH may be challenging because severe bilateral compression of neural elements in the spinal canal increases the risk of iatrogenic injury to nerve roots and dura. The surgical approach can be further complicated by calcification, hardening, and dehydration of the GDH tissue. The prevailing opinion in the literature is that giant disc herniations cannot safely be treated via tubular minimally invasive approaches.5-7 In this video, we present a case of a 52-yr-old male patient with a history of progressive low back pain that radiates bilaterally from the buttocks toward the posterior legs and knees for 2 yr because of a GDH at the L4-5 level. The patient was treated via a tubular "over-the-top" minimally invasive decompression in order to first provide generous bilateral decompression of neural elements and dura.8,9 After sufficient decompression at the surgical level, the discectomy was performed via an ipsilateral piecemeal resection of the GDH. The "over-the-top" contralateral mobilization of disc herniation was also achieved with this approach, which facilitated the removal of the entire disc fragment. Patient consent was obtained prior to performing the procedure. Therefore, GDH should not be considered as a contraindication for tubular decompression when this modified technique is performed.

Minimally Invasive Interlaminar Decompression with a 10-mm Endoscope and Microscope in Cases of Adult Degenerative Scoliosis

Adult degenerative (de novo) scoliosis (ADS) usually occurs due to degenerative changes and is accompanied by progressive low-back pain and/or symptomatic lumbar stenosis. Interlaminar decompression is considered an effective treatment of lumbar stenosis, but some surgical contraindications to traditional open surgery limit its application in elderly patients with many disorders. A 10-mm endoscope has been used in the treatment of stenosis in individuals with ADS and its safety and efficacy should be assessed. The objective was to conduct a retrospective analysis to compare interlaminar decompression with a 10-mm endoscope versus a microscope. Retrospective study. This study took place at the First Affiliated Hospital of Harbin Medical University. The data of 34 ADS patients treated in our hospital from January 2018 to December 2019, who underwent decompression with a 10-mm endoscope (ES group, 19 patients) or microscope (MS group, 15 patients) were retrospectively reviewed. The two methods were compared using the visual analog scale (VAS), Japanese orthopedic association (JOA) scale, and Oswestry disability index (ODI). Lumbar stability was also evaluated by the progression of scoliosis. There were no significant differences between the 2 groups in demographic or clinical characteristics. The mean preoperative Cobb angle of all patients was 23.34° ± 6.44°, which indicated degenerative scoliosis. The mean JOA and ODI scores were 8.09 ± 1.44 and 55.47 ± 11.91. The mean preoperative pelvic incidence (PI) and lumbar lordosis (LL) angles were 51.02° ± 7.21 and 38.26° ± 6.98 and the mean PI-LL mismatch was 12.76° ± 5.63. There was no significant difference in the VAS scores for back/leg pain between the groups at 1 week after the operation, but the scores of the ES group were significantly higher than those of the MS group at 3 months and 12 months. There were no significant differences of mean JOA and ODI between the ES and MS groups preoperatively, at 3 months, or at 12 months, but the JOA and ODI scores of the ES group were significantly higher than those of the MS group 1 week after the operation. The study showed that a novel method for the minimally invasive treatment of ADS is feasible; the safety and outcomes of this method should be verified with more cases. Minimally invasive decompression with a 10-mm endoscope was suggested to be a safe and effective method, as expected, for the treatment of lumbar stenosis in ADS patients.

Dural splitting reconstruction in retethering after lipomeningocele repair: Technical note.

Background: Tethered spinal cord syndrome (TCS) can occur after the surgical repair of lipomeningoceles (LMCs). In these cases, the tethering results from postoperative adhesions between the spinal cord and the overlying repaired dura. A watertight dural closure using the residual dura and/or the surrounding tissues does not always provide enough space for the spinal cord and risks retethering. Here, we report a 16-year-old patient with secondary TCS following lipomeningocele repair who successfully underwent release of the tethered filum terminale utilizing a novel dural splitting reconstructive technique to attain a water-tight closure without the need for a duroplasty.Methods: A 16-year-old patient had a LMC repaired at birth. She now presented with progressive low back pain, and gait disturbances. The MRI documented secondary spinal cord tethering at the prior spinal dysraphism repair site.Results: A secondary release of the filum terminale utilizing a novel dural splitting technique to avoid the need for a duroplasty was performed.Conclusion: Here, in a 16-year-old patient with a recurrent tethered cord syndrome following repair of a LMC at birth, we utilized a novel dural splitting reconstruction technique and averted the need for a duroplasty.

Sacral chordoma with incidental rectal adenocarcinoma: a case report

BackgroundWe report a unique case of synchronous sacrococcygeal chordoma in association with rectal invasive adenocarcinoma. Retrorectal tumors are a rare disease caused by a variety of pathologies. To our knowledge, no prior cases of such a coincidental finding of both cancers have been reported in the literature.Case presentationThis is the case of a 74-year-old white middle eastern man, with known hypertension under treatment, who presented with complaints of progressive lower back pain associated with urinary incontinence over the past 12 months. Magnetic resonance imaging (MRI) of the pelvis showed a large midline, well-defined, oval-shaped lesion replacing the sacrococcygeal portion of the spine, with extension to the presacral region. Computed tomography (CT)-guided Tru-Cut biopsy revealed features suggestive of chordoma. At surgery, we performed excision of the entire mass en bloc, sacrectomy with rectus abdominis myocutaneous flap reconstruction and end sigmoid colostomy. Surgical histopathology proved it to be sacral dedifferentiated chordoma and rectal invasive adenocarcinoma. Overall, the patient recovered well postoperatively, was discharged home with functional stoma and on permanent Foley catheter use.ConclusionTo the best of our knowledge, this is the only reported case of such a presentation, and sheds light on the approach and management. We hope that reporting such a case will add value to the medical literature.

Multiple Myeloma Course with Renal Insufficiency in Young Patient: Case Report

Introduction: Multiple myeloma (MM) is a malignant neoplasm characterized by the clonal proliferation of abnormal plasma cells in the bone marrow (OM). The average age of patients diagnosed with MM is approximately 70 years, being relatively uncommon in younger individuals. Objective: To report a case of a young patient with multiple myeloma. Case Description: A 42-year-old male patient presented with continuous and progressive low back pain for 3 months, associated with adynamia, weight loss (10 kg), episodes of constipation and bleeding in the oral cavity in this period. Examinations at the first appointment revealed moderate anemia (Hb 7.4 g / dL), leukocytosis, thrombocytopenia, hypercalcemia, and altered renal function (Cr 5.9 and Ur 178), chest tomography indicating vertebral fracture in T6, T11, L2 and L4. Referred for specialized follow-up, he performed electrophoresis of serum proteins with the presence of a monoclonal peak in the gamma globulin fraction. The immunofixation test confirmed monoclonality for IgA isotype and Kappa light chain (IgA / Kappa). The myelogram showed plasmacytosis of more than 50% of mononuclear cells in the bone marrow. He developed renal failure (with dosage of creatinine of 10.1 mg/ dL. and urea of 208 mg/dL) and hypercalcemia requiring dialysis therapy on the third day of hospitalization, having undergone chemotherapy with Bortezomib, cyclophosphamide and dexamethasone. During this period, infection by the multisensitive S. aureus in catheter occurred and, despite being treated with specific antibiotic therapy, it evolved with clinical worsening and hemodynamic instability and was referred to the Intensive Care Unit, going to death after 2 days. Conclusion: Young patients with MM may study with more aggressive characteristics. Despite the use of new therapeutic agents, more effective treatment strategies need to be studied more for patients in this age group. Disclosures No relevant conflicts of interest to declare.

Neglected lumbar traumatic spine injury after falling from a tree

This 48-year-old man, previously healthy, presented with a six-month history of progressive low back pain and bilateral pseudo-sciatica of the lower extremities without sphincter disturbances. Physical examination revealed fixed kyphotic posture of the lumbar spine. Straight leg test and tendon reflexes were normal without any neurologic deficits. He reported sustaining a traumatic injury two years earlier secondary to a fall from a tree. At that time, he did not seek medical treatment. Plain radiograph (A) demonstrated regional lumbar kyphosis from L1 to L3 as well as a healed burst fracture of L2 vertebra (star). Spinal lumbar computed tomography scan (B-C) confirmed traumatic kyphotic deformity at L1-L2-L3 and moderate central stenosis at L2. There was also a new joint surface formation and vacuum phenomenon between the anterior vertebral bodies of L1 and L3. The patient was counseled on the need for surgery, but he refused any surgical intervention and insisted on conservative management. Neglected lumbar spinal injuries are rare but serious clinical situations. Their etiologies vary from missed injuries, delayed presentation for treatment, and wrong initial management. The clinical symptoms include spinal and/or radicular pain, scoliotic and/or kyphotic deformity, and neurological deficits. Management of these neglected injuries is difficult with respect to intraoperative difficulties, higher incidence of surgical complications, and subsequent rehabilitation.

2679 Management of a Large Uterus and its Complications to a Successful Laparoscopic Surgery

Video Objective Present and demonstrate a pre operative and surgical management of large uterus and its complications. Setting A 37-years-old, G2P2, who complained of progressive dysmenorrhea, genital pelvic and low-back pain without improvement with hormonal treatment. Complementary exams showed deep endometriosis on the posterior compartment, myomatosis uterus with 848cc of volume and an 139cc cystic right ovarian mass, which generated an extrinsically compression on the right ureter and ureterohydronephrosis. Interventions Pre operative management consisted in double J catheter in the right ureter and uterine artery embolization with prophylactic antibiotic 3 months before the surgery. Final complementary exams showed an uterine volume reduction to 313cc. Laparoscopic treatment consisted of inspecting pelvic and abdominal cavities. Right ovarian mass was adhered to the posterior compartment including ovarian fossa, rectovaginal septum and right uterossacral ligament. Strategy consisted of right ovariectomy, Latsko and Okabayashi space dissection to identify bilateral hypogastric nerves and ureters. After identifying anatomy landmarks, endometriotic lesions were removed from uterossacral ligament and ureter. Rectovaginal septum was dissecated and bowel superficial lesion identified. Hysterectomy and bilateral salpingectomy were performed as treatment. Linear stapler was used to remove bowel endometriotic lesion. Ureterohydronephrosis became absent and controlled and Double J catheter was removed right after the surgery. Double J catheter right after surgery. Conclusion Pre operative strategies are very important to a successful surgery. Double J catheter is a temporary intervention to prevent ureteres complications. Uterine artery embolization reduced more than 50% of the uterine volume. These strategies facilitated the access to the pelvis and promoted excellent laparoscopic view to completely treat myomatosis and deep endometriosis.

Progressive Asymmetric Low Back Pain in a Young Basketball Player

Progressive Asymmetric Low Back Pain in a Young Basketball Player

Neuroschistosomiasis mimicking lower back pain: case report of a rare differential diagnosis in a pediatric patient

BackgroundSpinal myelitis is an infrequent manifestation of spinal cord infection. It is caused by the Schistosoma species, which are endemic in South America, part of the Middle East, and Africa.Case presentationWe report the case of a 13-year-old male adolescent complaining of progressive lower back pain and weakness of the lower extremities for 3 days. Initial magnetic resonance imaging revealed typical transverse myelitis. Subsequently, parasite serology showed a markedly elevated level of Schistosoma antibody titers, and cerebrospinal fluid analysis yielded normal results. Because of our presumptive diagnosis of neuroschistosomiasis, the patient was prescribed an empirical regimen of an anti-parasitic agent, after which his neurological deficit promptly subsided. The patient was followed for 1 year and showed a complete long-term resolution of symptoms.ConclusionsThis case highlights the increasing prevalence of neuroschistosomiasis in recent years, particularly in patients with a history of travel to endemic regions. Moreover, the study reports the clinicoradiological features of this enigmatic disorder. This rare occurrence potentiates further studies to address unanswered questions about neuroschistosomiasis.

Vertebral fracture after removing pedicle screws used for posterior lumbar interbody fusion: A case report

It is uncommon to remove pedicle screws after posterolateral lumbar interbody fusion (PLIF), and there are a few case reports of vertebral fracture involving holes remaining after screw removal. We report a case of the vertebral fracture after removing pedicle screws instrumented for PLIF. A 66-year-old woman with osteopenia, who underwent PLIF at L4–S1 10 years earlier, underwent PLIF at L3–L4 to correct adjacent-segment degeneration. We removed L5 and S1 pedicle screws, and inserted L3 pedicle screws. After surgery, she presented with severe progressive low back pain. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed an L5 body fracture involving the pedicle screw holes. Revision surgery, including posterolateral fusion from L3 to S2 alar iliac and L5 vertebroplasty, was performed. One year after the revision surgery, the patient remained pain-free and returned to normal activity. Possible reasons for instrumented vertebral body fracture after pedicle screw removal are decrease of vertebral mass, increased mechanical stress caused by PLIF at the adjacent segment, stress-shielding-related osteopenia, and spinal imbalance. Vertebral body fractures associated with spinal implant removal are rare, but possible, especially in elderly patients with osteopenia and osteoporosis.

Poster 330: Importance of Advanced Imaging in Evaluation of Progressive Low Back Pain: A Case Report

Poster 330: Importance of Advanced Imaging in Evaluation of Progressive Low Back Pain: A Case Report