Delayed postoperative neurological complication in a patient with congenital kyphoscoliosis: recovered by revision of the 4-rod instrumentation technique

Case report

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The authors report a case of progressive congenital kyphoscoliosis in which the patient, a boy, originally underwent combined anterior and instrumented posterior spinal fusion at the age of 7 years and 3 months. Early proximal junctional kyphosis and implant failure mandated proximal extension of implants with 2 new rods connected to the old caudad short rods. At the 3-year follow-up, clinical and CT assessment revealed a thoracolumbar pseudarthrosis for which the patient underwent a 2-stage procedure without complication. Recordings of somatosensory evoked potentials intraoperatively were normal. Twelve hours after surgery, his neurological status started to progressively deteriorate. The patient was brought to the operating room, and the initially achieved correction was reversed by an apex-only exposure of the 4-rod system. After surgery the patient started to show progressive improvement in his neurological function. A final myelography was performed and showed free passage of the dye without evidence of obstruction. Clinically, the patient continued to improve and at his 3-month follow-up had near-complete resolution of his neurological deficits. Findings on his physical examination were normal at the final 12-year follow-up.

Despite normal findings on intraoperative neuromonitoring, a delayed neurological deficit can occur after complex spine reconstruction. Preoperative risk assessment, surgical approach, and instrumentation deserve careful attention. Advantages of a 4-rod construct are discussed in this case.

Abbreviations used in this paper:MEP = motor evoked potential; SSEP = somatosensory evoked potential.

Article Information

Address correspondence to: Behrooz A. Akbarnia, M.D., San Diego Center for Spinal Disorders, 4130 La Jolla Village Dr., Suite 300, La Jolla, CA 92037. email:

Please include this information when citing this paper: published online September 20, 2013; DOI: 10.3171/2013.8.SPINE121160.

© AANS, except where prohibited by US copyright law.



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    Preoperative anteroposterior (A) and lateral (B) radiographs and (C) 3D CT reconstruction of the spine showing multiple congenital anomalies in thoracolumbar and lumbosacral regions. Postoperative anteroposterior (D) and lateral (E) radiographs of the patient showing instrumentation from T-9 to S-1.

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    Anteroposterior (left) and lateral (right) radiographs obtained in the patient after revision of instrumentation with the 4-rod construct to T-4.

  • View in gallery

    Anteroposterior (left) and lateral (right) radiographs at the latest follow-up.


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