The Spine Journal 14 (2014) 2783–2784
Heterotopic ossification after transforaminal lumbar interbody fusion without bone morphogenetic protein use We report a case of severe, intracanal heterotopic ossification in a 54-year-old man following L5–S1 transforaminal lumbar interbody fusion (TLIF). The patient presented to our clinic with recurrent low back pain, radiating left lower extremity pain and left L5 motor weakness (four of five strength) after previous left L5–S1 decompression (7 years prior), and left L4–L5 decompression and revision left L5–S1 decompression (1 year prior). Imaging studies demonstrated L5–S1 degenerative disc disease, spondylosis, and left L4–L5/L5–S1 foraminal stenosis. He underwent revision decompression from L4 to L5 and L5 to S1, and L5 to S1 TLIF with bilateral pedicle screw instrumentation and local autograft. Immediately postoperative, the patient had significant improvement in his lower extremity symptoms, and at 3 months postoperatively, he was able to return to work and was very satisfied, with complete relief of symptoms.
The patient was subsequently readmitted for pain management 6 months postoperative for acute worsening of his low back pain and recurrence of his left leg pain. Magnetic resonance imaging demonstrated an acute left paracentral disc herniation at L4–L5 (Fig. 1), and computed tomography scan demonstrated heterotopic ossification (HO) along the medial border of the L5–S1 TLIF decompression/cage insertion track with encroachment on the canal (Fig. 2, A–D). The formation of such severe intracanal HO without the use of bone morphogenetic protein or other adjuncts is unusual after TLIF. The patient had gradual improvement of his symptoms after analgesic medications and transforaminal corticosteroid injection. Given the patient’s clinical improvement, we will continue to observe him for any progression of the HO or development of new symptoms. Scott C. Wagner, MDa,b Daniel G. Kang, MDa,b Melvin D. Helgeson, MDa,b a Department of Orthopaedics Walter Reed National Military Medical Center 8901 Wisconsin Ave Bethesda, MD 20889, USA b Division of Orthopaedics, Department of Surgery Uniformed Services University of the Health Sciences 4301 Jones Bridge Rd Bethesda, MD 20889, USA FDA device/drug status: Approved (BRYAN Cervical Disc Arthroplasty). Author disclosures: SCW: Nothing to disclose. DGK: Nothing to disclose. MDH: Nothing to disclose. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government. All the authors are employees of the US government. This work was prepared as part of their official duties, and as such, there is no copyright to be transferred. No reproduced copyrighted materials are included in this study. No funds were received in support of this work. IRB approval with publication clearance was obtained for this study.
Fig. 1. Axial magnetic resonance imaging of the lumbar spine demonstrating acute left paracentral disc herniation at L4–L5. http://dx.doi.org/10.1016/j.spinee.2014.06.032 1529-9430/Published by Elsevier Inc.
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Fig. 2. Computed tomography scan of the lumbar spine with axial (A and B) and sagittal (C and D) reconstructions at 6 months postoperative demonstrating heterotopic ossification within the TLIF decompression and cage track, with encroachment on the canal. TLIF, transforaminal lumbar interbody fusion.
Heterotopic ossification after transforaminal lumbar interbody fusion without bone morphogenetic protein use We report a case of severe, intracanal heterotopic ossification in a 54-year-old man following L5–S1 transforaminal lumbar interbody fusion (TLIF). The patient presented to our clinic with recurrent low back pain, radiating left lower extremity pain and left L5 motor weakness (four of five strength) after previous left L5–S1 decompression (7 years prior), and left L4–L5 decompression and revision left L5–S1 decompression (1 year prior). Imaging studies demonstrated L5–S1 degenerative disc disease, spondylosis, and left L4–L5/L5–S1 foraminal stenosis. He underwent revision decompression from L4 to L5 and L5 to S1, and L5 to S1 TLIF with bilateral pedicle screw instrumentation and local autograft. Immediately postoperative, the patient had significant improvement in his lower extremity symptoms, and at 3 months postoperatively, he was able to return to work and was very satisfied, with complete relief of symptoms.
The patient was subsequently readmitted for pain management 6 months postoperative for acute worsening of his low back pain and recurrence of his left leg pain. Magnetic resonance imaging demonstrated an acute left paracentral disc herniation at L4–L5 (Fig. 1), and computed tomography scan demonstrated heterotopic ossification (HO) along the medial border of the L5–S1 TLIF decompression/cage insertion track with encroachment on the canal (Fig. 2, A–D). The formation of such severe intracanal HO without the use of bone morphogenetic protein or other adjuncts is unusual after TLIF. The patient had gradual improvement of his symptoms after analgesic medications and transforaminal corticosteroid injection. Given the patient’s clinical improvement, we will continue to observe him for any progression of the HO or development of new symptoms. Scott C. Wagner, MDa,b Daniel G. Kang, MDa,b Melvin D. Helgeson, MDa,b a Department of Orthopaedics Walter Reed National Military Medical Center 8901 Wisconsin Ave Bethesda, MD 20889, USA b Division of Orthopaedics, Department of Surgery Uniformed Services University of the Health Sciences 4301 Jones Bridge Rd Bethesda, MD 20889, USA FDA device/drug status: Approved (BRYAN Cervical Disc Arthroplasty). Author disclosures: SCW: Nothing to disclose. DGK: Nothing to disclose. MDH: Nothing to disclose. The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government. All the authors are employees of the US government. This work was prepared as part of their official duties, and as such, there is no copyright to be transferred. No reproduced copyrighted materials are included in this study. No funds were received in support of this work. IRB approval with publication clearance was obtained for this study.
Fig. 1. Axial magnetic resonance imaging of the lumbar spine demonstrating acute left paracentral disc herniation at L4–L5. http://dx.doi.org/10.1016/j.spinee.2014.06.032 1529-9430/Published by Elsevier Inc.
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S.C. Wagner et al. / The Spine Journal 14 (2014) 2783–2784
Fig. 2. Computed tomography scan of the lumbar spine with axial (A and B) and sagittal (C and D) reconstructions at 6 months postoperative demonstrating heterotopic ossification within the TLIF decompression and cage track, with encroachment on the canal. TLIF, transforaminal lumbar interbody fusion.
