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Case Presentation

This case presentation discusses a 70-year-old male with Ehlers-Danlos Syndrome who has undergone multiple failed spinal fusions. The patient experiences incapacitating back and leg pain and is unable to stand upright. The presentation includes operative issues, an operative plan, and postoperative outcomes.

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Case Presentation

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Presentation Transcript

  1. Department of Orthopedic Surgery Case Presentation Jeffrey M. Spivak, M.D.

  2. 70 y/o male retired opera singer H/o Ehlers-Danlos Syndrome Multiple prior spinal surgeries: Initial procedure – decompression with removal of synovial cyst L4-5 One year later – L4-S1 posterior decompression and fusion Two years later – Posterior decompression and fusion L2-4 <1 year later – Anterior/posterior fusion L2-5 Anterior iliac autograft, instrumented L2-3 Posterior instrumentation L3-5 Two years postoperatively: Incapacitating back and bilat. leg pain with inability to stand upright No significant focal neurologic findings Maintained on high dose narcotics (oral and patch), Neurontin, Flexaril, Lidoderm The Patient Division of Spine Surgery

  3. Two Years Since A/P Fusion Division of Spine Surgery

  4. Division of Spine Surgery

  5. ERECT SUPINE Division of Spine Surgery

  6. Division of Spine Surgery

  7. LEFT RIGHT CORONAL Division of Spine Surgery

  8. Operative Issues Fusion • Pseudoarthrosis L2-3, L3-4; healed L4-5, L5-S1 • Multiple past failed fusions Decompression (L2-3) • L2-3 • Direct vs. indirect (realignment) Sagittal imbalance • Focal at L2-3 • Flat Thoracic Spine Division of Spine Surgery

  9. Operative Plan Posterior (day 1) • Screw fixation T10-S1 • Laminectomy L2-3 Anterior (day 2) • Corpectomy L2 • Anterior fusion T10-L3 • Anterior fixation L1-2 to stabilize graft • Femoral allograft with BMP and rib graft Posterior (day 2) • Iliac bone graft • Rod fixation T10-pelvis Division of Spine Surgery

  10. Two Months Postoperatively 7 cm Division of Spine Surgery

  11. One Year Postoperatively 8 cm Division of Spine Surgery

  12. Two Years Postoperatively • Significant increase in pain • Again unable to stand upright Division of Spine Surgery

  13. ERECT SUPINE Division of Spine Surgery

  14. Division of Spine Surgery

  15. Operative Issues Fusion • Failed through posterior fusion mass at L5-S1 • Healed new fusions T10-L4 Sagittal imbalance • Focal at L5-S1 • PJK above T10 Division of Spine Surgery

  16. Operative Plan Anterior • ALIF L5-S1 with fixation • Femoral allograft with BMP Posterior • Instrumented fusion T3-pelvis • Iliac autograft, local bone, BMP Division of Spine Surgery

  17. 6 Months Postoperatively Division of Spine Surgery

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