A man in his 60’s consulted me with intractable back pains associated with degeneration of his lumbar spine. There was widespread degeneration of the lumbar facets and discs, and he presented with a significant history of narcotic use, in a vane attempt to get his pains better controlled.
Consultation at that stage and discussions regarding options for management ultimately lead to attempt at surgical correction of his pains, having failed other conservative treatment options over the years leading up to his surgical review. A long construct fusion was undertaken with screws from T9 down to the pelvis and whilst there were initial improvements in the discomforts, the patient represented with worsening pains down low in his back roughly 12 months later. Scans at the time revealed that the construct had failed, with the rod disengaged from the screws at the sacral level and loosening of the screws at L5. The stress and forces applied to the spine during the attempted spinal reconstruction were excessive and failure ensued. The lower screws were removed.
Despite improvement in his local symptoms (pains down low in his lumbar spine), he developed progressive deformity and spinal imbalance, with widespread pain and disability. His L4/5 and L5S1 segments became kyphotic throwing his balances forward significantly. He was back on his narcotic medication (kapanol 100mg bd) and was only able to ambulate with the assistance of a 4 wheel walker.
Standing x-rays at the time revealed the extent of his spinal deformity. His imbalance was pronounced with his head well forward of the expected balance point over the pelvis.
Consultation was sought from Dr Steven Yang, colleague, and expert in spinal deformity correction. After careful consultation and consideration of the case, a combined surgical case was undertaken with Dr Yang to address the imbalance issues.
In a 10 hour procedure involving neurosurgery and orthopaedic surgery, pedicle ubtraction osteotomies were undertaken to allow for restoration of the sagittal balances – ultimately allowing the patient to be able to stand upright once again.
His pain improved considerably and his narcotic use has decreased. He was off all Kapanol and using endone sparingly. He was far from perfect, but was considerably better, and he considered that his major reconstruction was well worth while.
A combined approach with neurosurgeons and expert orthopaedic spinal surgeons saw a great outcome in this case. Selected patients with spinal deformity will do very well from spinal reconstruction surgeries. Risks of this type of surgery are considerable, but in carefully selected cases with extensive counselling, lives can be turned around.
Dr Michael Bryant, Neurosurgeon and Spinal Surgeon