Revision for 67-y/o With Proximal and Distal Junctional Kyphosis
Alex Whiting, MD, Juan Uribe, MD
Barrow Neurological Institute
A 67-year-old female presented with incapacitating back pain and severe sciatica pain. She had previously undergone a L1 – L5 interbody fusion with posterior percutaneous pedicle screw fixation with cement augmentation. She attempted conservative management with no response.
The patient was neurologically intact.
Imaging demonstrated proximal junctional kyphosis and distal junctional kyphosis at T12-L1 and L5-S1, with a large herniated disc at L5-S1.
Proximal and distal junctional kyphosis.
LL: 310, PL: 560 , SVA: 11 cm
CT demonstrating vacuum phenomenon at L5-S1 and T12-L1
The goal of the surgery was to restore appropriate sagittal balance and lumbar lordosis. To achieve this outcome we decided to do a 3-stage minimally invasive procedure with:
Stage 1: L5 – S1 anterior lumbar interbody fusion.
Stage 2: T11 – L1 lateral lumbar interbody fusion, with T12 – L1 anterior column release.
Stage 3: T10 – Ilium percutaneous pedicle screw fixation.
We placed percutaneous screws from T10-Ilium, skipping the previously fixated levels, and used a computer-assisted rod bending system to contour the rod to our desired parameters before passing it percutaneously.
Stage 1: L5-S1 anterior lumbar interbody fusion with anterior column release.
Stage 2: T11-L1 lateral interbody fusion with T12-L1 anterior column release.
Stage 3: Posterior percutaneous T10-Ilium fixation with the use of a computer-assisted rod bending device and connection to prior rod construct.
By utilizing a minimally invasive approach, we were able to achieve the surgical goals, with minimal soft tissue disruption and an estimated blood loss of less than 400 cc.
By performing a L5-S1 anterior lumbar interbody fusion with a hyper-lordotic graft, we provided 18° of additional lordosis. We then performed a T11-L1 lateral lumbar interbody fusion with an anterior column release at T12-L1. This provided 12.5° of lordosis, as well as a large interbody graft for anterior fusion.
By placing a second rod percutaneously we were able to leave the prior fusion construct intact and link into the prior rod using connectors.
Pre-op: LL 310 PL: 560 SVA: 11 cm
Post-op: LL: 610 PL: 560 SVA: 2 cm