Sacral fractures following stand-alone L5–S1 anterior lumbar interbody fusion for isthmic spondylolisthesis

Report of 3 cases

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Recent studies have demonstrated excellent results in treating isthmic spondylolisthesis via an anterior lumbar interbody fusion (ALIF). The authors describe 3 patients with isthmic spondylolisthesis at L5–S1 who experienced sacral fractures after insertion of a unique, stand-alone anterior interbody fixation device.

Three consecutive patients at a single institution were treated for Grade I spondylolisthesis at L5–S1 via a standalone ALIF with insertion of a novel biomechanical interbody device. This device is made of polyetheretherketone and has an integrated system for internal fixation into the vertebral bodies. In each patient a bone morphogenetic protein–soaked sponge was placed for the fusion. The indications for treatment in each patient were back and radicular pain that had been unsuccessfully treated with conservative measures.

All 3 patients had reduction of their spondylolisthesis and resolution of their unilateral radiculopathies immediately postoperatively. Within 1 month of surgery, all 3 patients had failure of the device and recurrence of their symptoms. In each case the failure was due to fracture of the anterior portion of the S-1 body. Each patient underwent reduction and pedicle screw fixation at L5–S1. In all cases, there was successful reduction in their recurrent spondylolisthesis and resolution of their radiculopathies.

Treatment of Grade I isthmic spondylolisthesis at L5–S1 with stand-alone ALIF and fixation can lead to sacral fracture from high stress loads at that level in the spine, and consideration should be made either for supplemental pedicle screw fixation or a completely posterior approach.

Abbreviations used in this paper: ALIF = anterior lumbar interbody fusion; VB = vertebral body.

Article Information

Address correspondence to: Eric M. Horn, M.D., Ph.D., Department of Neurological Surgery, Indiana University College of Medicine, 545 Barnhill Drive, 139 Emerson Hall, Indianapolis, Indiana 46202-5124. email: emhorn@iupui.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Preoperative lateral radiograph demonstrating a Grade I spondylolisthesis at L5–S1.

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    Case 1. Intraoperative lateral fluoroscopic image showing reduction and foraminal height restoration at L5–S1 following insertion of the stand-alone ALIF device.

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    Case 1. Sagittally reconstructed CT scan obtained 1 month after surgery, demonstrating fracture of S-1 and recurrence of the spondylolisthesis.

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    Case 1. Lateral radiograph following percutaneous pedicle placement, demonstrating reduction and stabilization of L5–S1.

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    Case 2. Preoperative lateral radiograph demonstrating a Grade II spondylolisthesis at L5–S1.

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    Case 2. Sagittally reconstructed CT scan showing an S-1 fracture after placement of the stand-alone ALIF cage.

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    Case 3. Sagittally reconstructed CT scan obtained 9 months postoperatively, demonstrating solid fusion through and around the construct at L5–S1.

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    Case 1. Schematic demonstrating the S-1 fracture and the stress vectors contributing to this fracture. CG = center of gravity.

References

  • 1

    Breme JBiehl AHoffmann A: Tailor-made composites based on titanium for medical devices. Adv Eng Mater 2:2702752000

  • 2

    Chou DLu DCWeinstein PAmes CP: Adjacent-level vertebral body fractures after expandable cage reconstruction. J Neurosurg Spine 8:5845882008

    • Search Google Scholar
    • Export Citation
  • 3

    Davis JR: Physical and Mechanical Requirements for Medical Device Materials. Handbook of Materials for Medical Devices Materials Park, OHASM International2003. 1217

    • Search Google Scholar
    • Export Citation
  • 4

    Frei HOxland TRRathonyi GCNolte LP: The effect of nucleotomy on lumbar spine mechanics in compression and shear loading. Spine 26:208020892001

    • Search Google Scholar
    • Export Citation
  • 5

    Hsieh PCKoski TRO'Shaughnessy BASugrue PSalehi SOndra S: Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance. J Neurosurg Spine 7:3793862007

    • Search Google Scholar
    • Export Citation
  • 6

    Ishihara HOsada RKanamori MKawaguchi YOhmori KKimura T: Minimum 10-year follow-up study of anterior lumbar interbody fusion for isthmic spondylolisthesis. J Spinal Disord 14:91992001

    • Search Google Scholar
    • Export Citation
  • 7

    Kim NHLee JW: Anterior interbody fusion versus posterolateral fusion with transpedicular fixation for isthmic spondylolisthesis in adults. A comparison of clinical results. Spine 24:8128171999

    • Search Google Scholar
    • Export Citation
  • 8

    Kurtz SMDevine JN: PEEK biomaterials in trauma, orthopedic, and spinal implants. Biomaterials 28:484548692007

  • 9

    Kwon BKHilibrand ASMalloy KSavas PESilva MTAlbert TJ: A critical analysis of the literature regarding surgical approach and outcome for adult low-grade isthmic spondylolisthesis. J Spinal Disord Tech 18:SupplS30S402005

    • Search Google Scholar
    • Export Citation
  • 10

    Lee SHChoi WGLim SRKang HYShin SW: Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis. Spine J 4:6446492004

    • Search Google Scholar
    • Export Citation
  • 11

    Macintosh JEBogduk NPearcy MJ: The effects of flexion on the geometry and actions of the lumbar erector spinae. Spine 18:8848931993

    • Search Google Scholar
    • Export Citation
  • 12

    Madan SSHarley JMBoeree NR: Anterior lumbar interbody fusion: does stable anterior fixation matter?. Eur Spine J 12:3863922003

  • 13

    Mummaneni PVHaid RWRodts GE: Lumbar interbody fusion: state-of-the-art technical advances. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 1:24302004

    • Search Google Scholar
    • Export Citation
  • 14

    Ploumis AWu CFischer GMehbod AAWu WFaundez A: Biomechanical comparison of anterior lumbar interbody fusion and transforaminal lumbar interbody fusion. J Spinal Disord Tech 21:1201252008

    • Search Google Scholar
    • Export Citation
  • 15

    Spruit MPavlov PWLeitao JDe Kleuver MAnderson PGDen Boer F: Posterior reduction and anterior lumbar interbody fusion in symptomatic low-grade adult isthmic spondylolisthesis: short-term radiological and functional outcome. Eur Spine J 11:4284332002

    • Search Google Scholar
    • Export Citation
  • 16

    Spruit Mvan Jonbergen JPde Kleuver M: A concise follow-up of a previous report: posterior reduction and anterior lumbar interbody fusion in symptomatic low-grade adult isthmic spondylolisthesis. Eur Spine J 14:8288322005

    • Search Google Scholar
    • Export Citation

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