Rod Fracture Causing Relief of Back Pain That Developed After Adult Lumbar Degenerative Flat-Back Correction Surgery: A Case Report

Neurospine Neurospine 2019;16(4):789-792. https://doi.org/10.14245/ns.1836198.099 Case Report Corresponding Author Jee-Soo Jang https://orcid.org/0000-0003-0366-6070 Department of Neurosurgery, Nanoori Hospital Suwon, 295 Jungbo-daero, Yeongtong-gu, Suwon 16503, Korea Tel: +82-2-2660-7062 Fax: +82-32-8065-9701 E-mail: Received: September 4, 2018 Revised: November 27, 2018 Accepted: December 7, 2018 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2019 by the Korean Spinal Neurosurgery Society pISSN 2586-6583 eISSN 2586-6591 Rod Fracture Causing Relief of Back Pain That Developed After Adult Lumbar Degenerative Flat-Back Correction Surgery: A Case Report Jeong-Hoon Choi1, Jee-Soo Jang1, Il-Tae Jang2 Department of Neurosurgery, Nanoori Hospital Suwon, Suwon, Korea Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, Korea 1 2 A 73-year-old woman underwent deformity correction surgery (anterior lumbar interbody fusion of L2-L3-L4-L5-S1, pedicle subtraction osteotomy at L4, and posterior screw fixation from T10 to the pelvis) due to lumbar degenerative flat-back. Following the operation, the patient experienced pain in her back and buttocks, for which she regularly took medications. She reported frequently feeling a heavy and stretched sensation of pain after the operation in those areas, which made her regret undergoing the operation. However, at 33 months postoperatively, she reported that one day, while getting up from a chair, she felt a crack in her back, which was followed by an improvement in her back and buttock pain; thereafter, she stopped taking pain medications. Follow-up radiography revealed a bilateral rod fracture at the L4–5 level on the right side and at the L3–4 level on the left side. The overall pelvic parameters, except pelvic incidence, slightly changed after the rod fracture. Therefore, the broken rod was replaced and another rod was added to the broken rod area; however, the changed pelvic parameters were not corrected further during the reoperation. Following the reoperation, the patient showed improvements and she no longer required pain medication. Keywords: Lumbar, Osteotomy, Pelvic, Pain, Radiography INTRODUCTION revision surgery.3 In this study, we document and analyze the reasons for a rare case of a patient who reported an immediate improvement in her persistent pain in both her buttocks and leg as a result of adult lumbar degenerative flat-back surgery following the RF. A rod fracture (RF) can significantly affect patients, leading to, amongst others, pain, loss of deformity correction, and the need for revision surgery.1 Additionally, it may be a risk factor for pseudarthrosis if occurring soon after the operation. The largest study to date, which examined symptomatic RF, reported a lower incidence (6.8%) of symptomatic RF in an adult population of spinal deformity when treated with long ( > 5 levels) posterior instrumented fusion, and a higher incidence (15.8%) of the symptomatic RF in a subset of patients who underwent osteotomy.2 Nearly two-thirds of the patients (63.6%) with RF underwent revision and had lower scores in the Oswestry Disability Index (ODI) and in the 22-item Scoliosis Research Society questionnaire scores than did those who did not undergo CASE REPORT Institutional Review Board approval was obtained before initiating the study. A 73-year-old woman reported an improvement in pain in her back and buttocks following a “cracking” sound in her back. The patient described to have had back and buttock pain for several years as a result of her lumbar degenerative flat-back (Fig. 1A), for which she underwent deformity correction surgery (anterior lumbar interbody fusion of L2-L3 www.e-neurospine.org 789 Choi JH, et al. Pain Relieved by Rod Fracture A B C D Fig. 1. (A) Preoperative whole spine X-ray showing a positive sagittal imbalance. (B) Postoperative (ALIF L2-3-4-5-S1, pedicle subtraction osteotomy at L4, and posterior screw fixation from T10 to pelvis) whole spine X-ray showing the correction of the preoperative sagittal imbalance. (C) Bilateral rod fracture (arrow) at the L4–5 level on the right side and at the L3–4 level on the left side. (D) Change of the previous titanium rod to the current cobalt rod, with the addition of a titanium rod beside the cobalt rod. Table 1. Changes in spinopelvic parameters relative to the operation stage Parameter Preoperative POD #7 POD Rod After re#1 yr fracture operative SVA (mm) -254 -10 0 40 40 PI (°) 56 56 56 56 56 SS (°) -5 48 47 40 36 PT (°) 61 8 9 16 20 LL (°) 26 -65 -63 -50 -50 TL (°) 18 -1 -1 5 5 TK (°) 30 34 36 40 40 PI-LL mismatch (°) 30 -9 -7 6 6 LL-TK (°) -4 31 27 10 10 TPA (°) 71 1 5 16 16 POD, postoperative day; SVA, sagittal vertical axis; PI, pelvic incidence; SS, sacral slop; PT, pelvic tilt; LL, lumbar lordosis; TL, thoracolumbar lordosis; TK, thoracic kyphosis; TPA, T1-pelvic angle. L4-L5-S1, pedicle subtraction osteotomy [PSO] at L4, and posterior screw fixation from T10 to pelvis) 33 months ago (Fig. 1B). Her pelvic parameters described in Table 1, were measured before deformity correction, 7 days postoperatively, and 1 year postoperatively, following RF and reoperation. Following the operation, the patient experienced back and buttock pain for which she regularly took medications. She described the pain that frequently felt heavy and stretched in her back and buttock, 790 www.e-neurospine.org and also felt like being bulled her back posteriorly, which made her regret getting operated. Because of her severe pain, the patient has taken several steroid injection therapies at another hospital and pain medications (Ultracet tablet [tramadol hydrochloride 37.5 mg/acetaminophen 325 mg] and Targin tablet [oxycodone hydrochloride 5 mg/naloxone hydrochloride 2.5 mg]) ever since. Additionally, follow-up plain radiography did not reveal any complications. Considering that the postoperative pelvic parameters and sagittal balance were in the reference range, reoperation was not considered. However, 33 months after the operation (postoperative day #978), the patient noted an improvement in her back and buttock pain following a “cracking” sound in her back while getting up from a chair. However, this did not lead to any aggravation of the deformity and resulted in reduced back discomfort, for which pain medications were not required any longer. The following month, the patient visited the outpatient clinic and a follow-up plain radiography revealed a bilateral RF at the L4–5 level on the right side and at the L3–4 level on the left side (Fig. 1C), without a periscrew halo. We found the interbody bony formation between t (...truncated)