Posterior Instrumentation and Simultaneous Intertransverse Approach Using Transforaminal Cage Fusion for Thoracic Pseudoarthrosis in Ankylosing Spondylitis: A Case Report

Abstract

Background Unrecognized or untreated injury in patients with ankylosing spondylitis (AS) may develop anterior column spinal pseudoarthrosis with an open wedge bone defect. The methods of surgical treatment are controversial. Combined anterior and posterior stabilizations or posterior instrumentation with osteoclasis are beneficial as shown in an existing literature review.

Case Report A 36-year-old Asian man with AS sustained a motor vehicle accident 2 years before presentation. At that time, his immediate magnetic resonance imaging scan demonstrated T10–T11bone edema and granulation tissue formation with fluid accumulation in T10–T11 disc space. He opted for conservative treatment. His back pain was then exacerbated 2 years after the accident, and he underwent three-dimensional (3D) computed tomography (CT) scan revealing a severe pseudoarthrosis with sclerotic margins across the T10 caudal end vertebra to the T11 upper end plate, with a maximal fracture gap of 15 mm. Spinal cord compression was not present. After selecting for an appropriate cage size with the aid of the preoperative 3D CT images, we used a single posterior approach to apply pedicle screws, removed pseudoarthrotic granulation tissue through an intertransverse posterior lateral approach without entering the spinal canal, and inserted a transforaminal lumbar interbody fusion (TLIF) cage with bone graft. There was radiographic evidence of spinal fusion at the 9-month follow-up, and the patient had resumed all normal daily activities.

Conclusion The authors found that a less invasive single posterior surgical approach using a TLIF cage and pedicle screws could be applied to AS patients with combined thoracic pseudoarthrosis and an anterior column defect. Using a TLIF cage may provide circumferential stability immediately, bone graft fusion, and sagittal plane correction simultaneously. An appropriate cage size and placement selected with preoperative 3D CT images are the keys to success.

Keywords

ankylosing spondylitis - spinal pseudoarthrosis - transforaminal lumbar interbody fusion - three-dimensional CT

• References

• 1 Olerud C, Frost A, Bring J. Spinal fractures in patients with ankylosing spondylitis. Eur Spine J 1996; 5 (1) 51-55
• 2 Kim KT, Lee SH, Suk KS, Lee JH, Im YJ. Spinal pseudarthrosis in advanced ankylosing spondylitis with sagittal plane deformity: clinical characteristics and outcome analysis. Spine 2007; 32 (15) 1641-1647
• 3 Chen LH, Kao FC, Niu CC, Lai PL, Fu TS, Chen WJ. Surgical treatment of spinal pseudoarthrosis in ankylosing spondylitis. Chang Gung Med J 2005; 28 (9) 621-628
• 4 Wang G, Sun J, Jiang Z, Cui X. The surgical treatment of Andersson lesions associated with ankylosing spondylitis. Orthopedics 2011; 34 (7) e302-e306
• 5 Elgafy H, Bransford RJ, Chapman JR. Epidural hematoma associated with occult fracture in ankylosing spondylitis patient: a case report and review of the literature. J Spinal Disord Tech 2011; 24 (7) 469-473
• 6 Chang KW, Tu MY, Huang HH, Chen HC, Chen YY, Lin CC. Posterior correction and fixation without anterior fusion for pseudoarthrosis with kyphotic deformity in ankylosing spondylitis. Spine 2006; 31 (13) E408-E413
• 7 Hamburger C. Modification of costotransversectomy to approach ventrally located intraspinal lesions. Preliminary report. Acta Neurochir (Wien) 1995; 136 (1-2) 12-15
• 8 Rosenberg WS, Mummaneni PV. Transforaminal lumbar interbody fusion: technique, complications, and early results. Neurosurgery 2001; 48 (3) 569-574 , discussion 574–575
• 9 Fessler RG, Dietze Jr DD, Millan MM, Peace D. Lateral parascapular extrapleural approach to the upper thoracic spine. J Neurosurg 1991; 75 (3) 349-355
• 10 Gill JB, Levin A, Burd T, Longley M. Corrective osteotomies in spine surgery. J Bone Joint Surg Am 2008; 90 (11) 2509-2520
• 11 Uribe JS, Dakwar E, Cardona RF, Vale FL. Minimally invasive lateral retropleural thoracolumbar approach: cadaveric feasibility study and report of 4 clinical cases. Neurosurgery 2011; 68 (1, Suppl Operative): 32-39 , discussion 39
• 12 McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine 2006; 31 (11, Suppl): S70-S79 , discussion S104