Volume VI, Number 1 | March 2022

Anterior Vertebral Body Avulsion Fractures after Extreme Lateral Interbody Fusion and Minimally Invasive Posterior Lumbar Instrumentation and Fusion: A case report

Folau C, Maugle T, Parekh S, Yevtukh A
UPMC Pinnacle, Harrisburg, PA, United States

Interbody fusion of the degenerative lumbar spine can stabilize painful motion segments, indirectly decompress neural elements, restore lordosis, and correct deformities. Lateral lumbar interbody fusion (LLIF), also referred to as eXtreme Lateral Interbody Fusion (XLIF) or Direct Lateral Interbody Fusion Interbody Fusion (DLIF) is the focus of this report. Indications for XLIF include spondylolisthesis, adult de novo lumbar scoliosis, central and foraminal stenosis, degenerative disc disease, pseudoarthrosis, total disc arthroplasty conversion, among others.

An important advantage is a reduced risk of injury to major vascular or visceral structures when compared to other approaches. Additional benefits include increased disc space height, less blood loss, shorter operative time, and reduced length of stay. According to Sembrano et all, notable advantages that are particularly relevant in our case is the ability to improve lordosis, without resecting the ALL as performed during anterior lumbar interbody fusion (ALIF), and the ability to place interbody cages with a larger footprint than other approaches.

In this case, we present an unusual complication that occurred during a multilevel XLIF. We identified asymptomatic avulsion fractures of the anterior vertebral bodies of L2 and L3 after routine postoperative radiographs were obtained. This has not been well described in the literature. In fact, to our knowledge it has not been described at all. We aim to present the case details, background on the surgical indications, techniques, advantages/disadvantages to XLIF (DLIF/LLIF), and offer a possible mechanism explaining these fractures.

In conclusion, we report a case of intraoperative anterior vertebral body avulsion fractures at L2 and L3 during XLIF at L2-L3, L3-L4, and L4-L5. We propose the mechanism of intraoperative anterior vertebral body avulsion fractures during XLIF to have occurred due to the bone failing under shear forces between the anterior longitudinal ligament and vertebral body interface as implants were impacted, increasing disc height and lumbar lordosis. These fractures did not appear to be clinically important or result in adverse effects for our patient, but to our knowledge no descriptions of this phenomena are found in the literature, so the incidence and clinical relevance is unknown. We encourage surgeons to be cognizant of this iatrogenic injury and to carefully evaluate intra-op and postop images for this subtle fracture pattern. Improved diagnosis and documentation could help with better understanding the incidence, clinical significance, and mechanism of this phenomena.

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The Journal of the American Osteopathic Academy of Orthopedics

Steven J. Heithoff, DO, FAOAO

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Authors in This Edition

J. Michael Anderson BS, OMS IV
Rigel Bacani BA, BS, OMS II
David Beckett OMS I
Bhakti Chavan MBBS, MPH
Jake Checketts DO
Grant Chudik OMS II
Adam Dann
Marc Davidson MD
Clinton J. Devin MD
Jeffrey Dulik DO
Bryan Dunford BS, OMS II
Diego Galindo DO
Gregory Galvin DO
Curtis Goltz DO

Jordan Grilliot DO
Brian Handal
Safet Hatic
Scott Dean Hodges DO
David Houserman DO
Jenna Jarrell MS IV
Michael Jones DO
Anthony Kamson DO
Tyler Metcalf MS IV
Anna Elisa Muzio DO
Cesar Cornejo Ochoa OMS I
Brandi Palmer MS
Joseph Patrick
David Phillips DO

Jonathan Phillips MD
Kornelis Poelstra MD
Jesse Raszewski DO, MS
Katherine Sage DO
Steven Santanello DO, FAOAO
Jared Scott DO
Julieanne Sees
James Seymour DO
Jonathan Schneider DO
John Alex Sielatycki MD
Benjamin Taylor MD, FAAOS
Trevor Torgerson BS, OMS IV
Phong Truong DO
Matt Vassar PhD