gms | German Medical Science

Objectives: Multilevel spondylectomy and spondylodesis became a well established technique. We recently reported about a case of a 43-year-old gravedigger who underwent three-level en bloc spondylectomy and replacement of the aorta after chondrosarcoma (G2, R0) in 2007. We performed regular follow-ups (f/u) during which the patient showed himself fully reintegrated. Between 2014 and 2015 a implant failure was observed and we therefore advised revision surgery. This case report reflects management strategies and the one-year f/u.

Methods: 8 years after en-bloc resection of Th11 to L1 with partial replacement of the aorta, cage interposition, cement augmentation and dorsoventral stabilization we performed a two stage dorsoventral correction spondylodesis by i) dorsal removal of broken screws in Th9 and L2, removal of broken titanbars, correction of kyphosis, enlargement of the spyndylodesis from Th8 to L4 with titan screws and spongiosa transplantation and ii) ventral removal of the plate and the cage, implantation of an expandable three-level PEEK®-cage from Th11 to L1 and anterior stabilization from Th9/10 to L2/3 with screws and rods and spongiosa transplantation. Operation time was i) 301 minutes and ii) 598 minutes and intraoperative blood transfusion was 0 ml and 1370 ml respectively. Total time in hospital was 22 days before the patient could be discharged without neurovascular deficit and limited pain on the visual analogous scale (VAS) 2/10.

Results and Conclusion: One year after revision surgery the patient presented fully reintegrated with no painkillers needed. Pain was reported with 2/10 on the VAS. He reported free walking distance and that he was able to work as a gravedigger and regularly carries coffins (which we clearly did not encourage). Neurological evaluation showed no neurovascular deficit with full power for both lower extremities. F/u CT-scan of the thoracolumbar spine showed no hint for implant failure (Figure 1 [Fig. 1]).

Whereas the initial technique used a cement augmented ventral cage with plate fixation and dorsal stabilization the revision surgery was performed using a PEEK®-Cage with spongiosa and additive screw-bar fixation accompanied by posterior extension of the fixation. The advantage of the revision osteosynthesis is i) a better primary stability of the expandable cage, ii) a ventral plate is not necessary as the long dorsal stabilization defines the primary stabilization and iii) a too rigid ventral stabilization might facilitate stress shielding and secondary loosening which is avoided.