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Spinal Fusion
The Use of Accell Total Bone Matrix® in a Decompressive
Laminectomy at L4 and L4-L5 with Spinal Fusion at L4-L5 to Treat
Hemangioma with an L4 Fracture
Louis Keppler, M.D.
Brook Park, Ohio 44142
 Introduction
The use of a new osteoinductive bioimplant, Accell Total Bone
Matrix® (IsoTis OrthoBiologics, Inc., Irvine, CA), is
described in a patient undergoing a posterior lateral fusion
of L4 and L5 following collapse of L4 after treatment for
hemangioma.
The number of spinal surgeries increased 6.2% for patients
in United States hospitals between 2004 and 2005, with the
number of cases expected to exceed one million in 2005.1
Bone is used in over 450,000 procedures in the U.S. to repair
bone defects caused by trauma or tumor resection, and to achieve
spinal arthrodesis. However, the incidence of nonunions in
posterolateral lumbar fusions ranges from 5% to 44%, and annual
costs to treat back pain in the U.S. are estimated at $25
billion.2,3
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Patient Profile
A 52-year-old male presented with severe lower back pain, described
as aching and stabbing, as well as pain in his left buttock and
lower extremities. The patient was a non-smoker with no significant
history of other relevant conditions. Pain was limiting activity.
Two to three years prior to the procedure, the patient was diagnosed
with hemangiomas of the thoracic spine at regions within the T5
and T12 vertebral bodies and left pedicle of T12, and of the lumbar
spine at L4-5. At L4-5 there was 50% height loss with biconcave
appearance. There was retropulsion of bone with narrowing of the
central canal, with a minimal AP diameter of 4-5 mm. The vertebral
body expansion compromised the neural foramina. There was extension
into the left pedicle.
Injection into L4 to treat the hemangioma was performed and over
time there was progression of collapse of L4.
Surgical Method
After satisfactory anesthesia was obtained, the patient’s
back was prepped and draped in the standard sterile fashion. There
was a posterior exposure performed at
L4-5, carrying the dissection out to the transverse processes at
L4 and L5 bilaterally. A laminectomy was performed of L4, such that
it was co-linear with the medial wall of the pedicle. There was
evidence of compression secondary to the patient’s vertebral
body fracture associated with his hemangioma. The posterior decompression,
however, satisfactorily decompressed the space.
The nerve roots were completely free at L4 and L5 bilaterally. To
support the interspace, it was considered prudent to perform a posterior
fusion. To this end, the facet joint was decorticated, as well as
the area of the pars and the transverse processes bilaterally. A
bone graft was placed using the patient’s own bone from the
decompression as well as ground cortical cancellous bone and demineralized
bone matrix, Accell Total Bone Matrix®.
VSP screws were placed to the pedicles of L4-5 bilaterally. The
screws were stimulated with interoperative EMG’s and found
to be stimulated at appropriate levels. Intraoperative radiographs
confirmed satisfactory placement of the screws. Three millimeter
washers were placed over the screws and the VSP plate was contoured
appropriately and locked into place using a top locking nut torqued
to the appropriate setting.
When the final radiographs were confirmed as satisfactory, the machine
screw portion was transected above the top nut and the wound was
closed in layers.
Outcome
Within two weeks of the surgery, the patient complained of shortness
of breath and chest pain. Since there was a positive family history
for deep vein thrombosis, he was evaluated for a pulmonary embolism,
but it was ruled out.
Two months after the spinal fusion, the patient was feeling significantly
better. He was referred to the Cleveland Clinic for chronic pain
management. Radiographic images appeared stable. At four months,
pain was improved, radiographs continued to demonstrate stability
and the patient was told to wean himself from the back brace.
At five months post-operatively, the position of the implants were
satisfactory, but the patient’s backache continued. Leg pain
had decreased. By seven months the patient stated that he felt the
operation had helped greatly. There was some lateral pain and occasional
soft tissue swelling. By ten months, new symptoms related to the
thoracic area appeared, but the condition of the lower lumbar spine
remained stable.
Reference
1. 2005 Spinal Surgery Update. Orthopedic Network News, Volume 16,
Number 4, October 2005.
2. Vaccaro AR: The role of the osteoconductive scaffold in synthetic
bone graft. Orthopedics, (Supplement), May 2002.
3. U.S. Markets for Spinal Fusion Products. Medtech Insight, A303,
August 2005.
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