Department of Orthopedic Surgery Case Presentation Jeffrey M

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

The Patient ● 70 y/o male retired opera singer ● H/o Ehlers-Danlos Syndrome ● Multiple prior spinal surgeries: ● ● Initial procedure – decompression with removal of synovial cyst L 4 -5 One year later – L 4 -S 1 posterior decompression and fusion Two years later – Posterior decompression and fusion L 2 -4 <1 year later – Anterior/posterior fusion L 2 -5 ● Anterior iliac autograft, instrumented L 2 -3 ● Posterior instrumentation L 3 -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 Division of Spine Surgery Department of Orthopedic Surgery

Two Years Since A/P Fusion Division of Spine Surgery Department of Orthopedic Surgery

Division of Spine Surgery Department of Orthopedic Surgery

ERECT Division of Spine Surgery Department of Orthopedic Surgery SUPINE

Division of Spine Surgery Department of Orthopedic Surgery

LEFT RIGHT CORONAL Division of Spine Surgery Department of Orthopedic Surgery

Operative Issues Fusion • Pseudoarthrosis L 2 -3, L 3 -4; healed L 4 -5, L 5 -S 1 • Multiple past failed fusions Decompression (L 2 -3) • L 2 -3 • Direct vs. indirect (realignment) Sagittal imbalance • Focal at L 2 -3 • Flat Thoracic Spine Division of Spine Surgery Department of Orthopedic Surgery

Operative Plan Posterior (day 1) ● Screw fixation T 10 -S 1 ● Laminectomy L 2 -3 Anterior (day 2) ● ● Corpectomy L 2 Anterior fusion T 10 -L 3 Anterior fixation L 1 -2 to stabilize graft Femoral allograft with BMP and rib graft Posterior (day 2) ● Iliac bone graft ● Rod fixation T 10 -pelvis Division of Spine Surgery Department of Orthopedic Surgery

Two Months Postoperatively 7 cm Division of Spine Surgery Department of Orthopedic Surgery

One Year Postoperatively 8 cm Division of Spine Surgery Department of Orthopedic Surgery

Two Years Postoperatively ● Significant increase in pain ● Again unable to stand upright Division of Spine Surgery Department of Orthopedic Surgery

ERECT Division of Spine Surgery Department of Orthopedic Surgery SUPINE

Division of Spine Surgery Department of Orthopedic Surgery

Operative Issues Fusion ● Failed through posterior fusion mass at L 5 -S 1 ● Healed new fusions T 10 -L 4 Sagittal imbalance ● Focal at L 5 -S 1 ● PJK above T 10 Division of Spine Surgery Department of Orthopedic Surgery

Operative Plan Anterior ● ALIF L 5 -S 1 with fixation ● Femoral allograft with BMP Posterior ● Instrumented fusion T 3 -pelvis ● Iliac autograft, local bone, BMP Division of Spine Surgery Department of Orthopedic Surgery

6 Months Postoperatively Division of Spine Surgery Department of Orthopedic Surgery