PMC5357515_01
Crouched standing posture.
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Inspection of her posture on standing revealed severe sagittal plane deformity including lumbosacral kyphosis and lumbar hyperlordosis with flexion at hips and knees (crouched position) (Figure 1).
(a) Preoperative A-P radiograph lumbosacral spine. (b) Whole spine standing lateral view radiograph. (c) Flexion-extension lateral view of lumbosacral spine. (d) Sagittal reconstructed CT scan.
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Plain radiography and computed tomography (CT scan) showed L5 spina bifida occulta, bilateral L5 pars defect, dysplastic L5-S1 facets, trapezoidal L5 vertebral body, retroverted sacrum with rounding of proximal endplate, and complete anterior descent of the L5 vertebrae to the sacrum (Figures 2(a)-2(d)).
Sagittal T2 weighted MRI image.
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Magnetic resonance imaging (MRI) of lumbosacral region revealed severe dural compression at L5-S1 level and L5-S1 intervertebral disc degeneration (Figure 3).
Intraoperative image (1st-stage surgery) showing loose inner nut of L4 pedicle screw (broad arrow) before final wound closure.
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Rod inserted on this side was secured by tightening of inner screw of L5 and S1 screws, and those of L3, L4, and S2 screws were kept loose (Figure 4).
Postoperative standing lateral spine radiograph.
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Objective radiological measurements performed after surgery, which included percent displacement, slip angle, sacral inclination, total lumbar lordosis (L1-L5), and global sagittal balance (plumb line from centre of C7 in relation to posterosuperior edge of sacrum), showed marked improvement on comparison to presurgery measurements (Figure 5).
A-P and lateral radiograph of lumbosacral spine after 3-year follow-up.
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Radiological evaluation revealed disengagement of screw rod complex at proximal end of construct along left side and loosening with screw back out of S2 pedicle screws along lower end of the screw assembly (Figures 6(a) and 6(b)).
A-P and lateral radiograph of lumbosacral spine following 2nd-stage surgery.
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After preparing the end plates appropriate size titanium mesh cage was inserted, incorporated with bone graft obtained after harvesting autogenous rib (Figures 7(a) and 7(b)).
A-P and lateral clinical photograph one year postoperatively.
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During the most recent follow-up of about 12 months following the subsequent surgery, patient is pain-free and fully active and on clinical evaluation her spinal alignment was found to be appropriate (Figures 8(a) and 8(b)).