Traumatic Vertebral Fracture in a Patient With Transforaminal Lumbar Interbody Fusion: A Rare Complication

Abstract

Transforaminal lumbar interbody fusion (TLIF) offers the potential benefits of anterior and posterior column decompression and fusion. Pseudarthrosis and infection are among the most common perioperative complications. Vertebral fracture after TLIF is a rare and unusual complication. A 74-year-old female underwent L3-5 TLIF for lumbar spondylolisthesis that caused back pain and neurogenic claudication. She recovered well after surgery. However, she subsequently experienced progressive back pain and recurrent claudication after a fall. Elongated anterior-posterior length of the L5 body with progressive L5-S1 listhesis was observed in the serial radiographic follow-ups. The CT scan revealed complicated fracture lines crossing the L5 body. Further extended fixation was performed for decompression and reconstruction of the lumbosacral alignment. Although vertebral fracture after TLIF is a rare complication, a high index of suspicion is the key to early diagnosis, preferably with CT scans, for patients with traumatic accidents after TLIF surgery.

Keywords: computed tomography; spondyolisthesis; tlif; trauma; vertebral facture.

Figure 1. Preoperative radiograph and MRI

Illustration of the preoperative radiograph with L3-4 retrolisthesis and Meyerding Grade II spondylolisthesis over L4-5 (A), and the T2-weighted MRI with spinal stenosis over L3-5 (B) MRI: magnetic resonance imaging

Figure 2. Series of radiographs during subsequent follow-ups after L3-5 TLIF

The series of radiographs demonstrate the different time points of follow-up after L3-5 TLIF (A: immediate postoperative; B: two months postoperative; C: three months postoperative; and D: six months postoperative). The patient experienced a fall two months after TLIF. The radiograph arranged immediately after the episode (B) revealed no significant change, compared with the postoperative status. Elongated anterior-posterior length over L5 body with progressive listhesis was observed at postoperative three- and six-month follow-ups (C and D respectively). After the secondary surgery, L5 total laminectomy and extended fixation from L3 to S2 were performed to restore lumbosacral alignment (E) TLIF: transforaminal lumbar interbody fusion

Figure 3. L5 fracture on CT scans

Illustration of CT scans at six months after the first surgery and three months after the secondary surgery. After the patient had an accident by falling on the ground, a transverse fracture line across the right transverse to the L5 body with mild callus formation (A, dashed line), and a vertical fracture line over the posterior third of the L5 body with endplate destruction (B, arrowhead) were observed. The secondary surgery with L5 total laminectomy and extended fixation from L3 to S2 was performed. At the three-month postoperative follow-up, the CT scan revealed good bone healing over the transverse (C) and vertical fracture lines (D) after the secondary surgery CT: computed tomography