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A Case of Double Failed Lumbar Fusion and Dangerously Misplaced Pedicle Screws

A Case of Double Failed Lumbar Fusion and Dangerously Misplaced Pedicle Screws
hi guys dr. Douglas Dillard here welcome back to another video today we're going to talk about a

case

I actually did about eight months ago and I thought that was the end of the

case

but sadly the story continues it was a sad tale about a young man who suffered a

fusion

that went horribly wrong the doctors wouldn't pay any attention to him took 2.5 years to get a new CT to actually assess the original construct and to see what happened with the

fusion

and it went horribly wrong it was
a case of double failed lumbar fusion and dangerously misplaced pedicle screws
actually life-threatening after the publishing of this video the doctors miraculously called the patient back in and they did a revision surgery to fix the the dangerous things that went on with a

fusion

and I thought that was the end of it but no so the revision surgery unfortunately has went horribly wrong as well and now we're back in the same boat they again won't pay any attention to the patient's new complaints that happened after the vision surgery and there's you're
not gonna believe what you're gonna see I mean I don't understand why I have to keep making these videos to have them correct their mistakes according to the patient now and this is I'm only getting one side of the story but according to the patient they say the

fusion

construct is fine so I don't know here we go you you judge for yourself and before we go on I would like to quickly mention that I do offer a consultation service I call it a coaching service if you wanted to talk
with me personally I will put a link down below to my coaching service page and you can check it out and find out out about it give me an email if you would like further questions or have questions about it be happy to speak with you I use a program called GoToMeeting been doing it for G since 2003 so very long time you can check out my testimonial page I'll put a link to that I have great testimonials for medical doctors rocket scientists chiropractors physical therapists broadcasters
accountants you name at every profession you can imagine from every corner of the globe so be very happy to speak with you about your problem all right I'm gonna put my head down now let's get to this PowerPoint presentation I hope you enjoy it okay so here we go on the PowerPoint presentation so the title is

failed

back to back

fusion

s so this is a

double

failed

fusion

back to back and now this is a I want to say it's the third-world country it's almost a third-world country
going on although I don't know it's it's kind of modern I don't want to mention who it is per the patient's request but I've never seen a

case

like this apparently in this country there's no lawsuits are allowed and apparently you can have to have the same surgeon perform at once once he's your surgeon he's your surgeon you can't change which is unfortunately because he really made the same mistakes that he did in the first procedure so let's see what
happened so the civil column bill this is an update as I said it was original injury he did playing sports and this is classic of this spondylolysis when he was 20 years old it's got some congenital stuff going on as we'll see here in a minute but the pain slowly got worse and worse over the next five or six years low back pain and then a bilateral leg pain all the way down grade three sciatica tend to develop and it got disabling where he had to eventually stop school and stop working
because of the pain okay finally a CT scan was ordered he did try conservative care but nothing helped and that was the othera pianned exercise and i think he had some injections too nothing helped so a CT was ordered in 2015 let's see what the problem is so I'll stop right here now if you haven't watch my videos on how to read your MRI you're going to be completely lost I'm not going to teach you how to do that I'll put another link down below for how to read your MRI
videos where you can and I'm not trying to make you radiologists of course just give you an idea it's not really not that hard I don't think but you're gonna be lost my students will be find in my followers you guys should be fun so wait I see here this is a CT a midsagittal slice this is the sacrum down here l5 l4 l3 and we can see the vertebral canal here and students and followers how big should the vertebral canal be should be 20 millimeters is this 20 millimeters well
let's see that's 12 point 9 that's 12 point 9 that's 16 so no so this is a condition called congenital stenosis this is something he was born with so off the bat that immediately makes things a tight squeeze in here the nerve roots they actually in traversing nerves the Cossack the epidural venous plexus everything is a little squished not horribly squished 13 is normal or anything under 13 is considered central stenosis so he's just kind of on the border here but I mean he
sees only what 26 at the time of this video so but so this is kind of setting the setting the background for what has happened here with the patient there was no sign of slip though see the line of the bones if anything there's a slight retro Alice thesis at 3/4 but pretty good alignment no slip so let's take a look at another image okay now what do you see so this is a cut through the right intervertebral foramen so let's look at l4 first there's a vertebral body superior
articular process inferior articular process this whole thing is the articular piller here's the pars interarticularis this is the weakest region of bone in the human there's a Z joint a cap off the seal joint here there's the other one so what do you see got a cut line going right through it he's scattered he's got a fracture so here's a big fracture in the pars and we can go to the overhead view remember this is the cut line so whatever that line goes through you'll
see on this video this slot this side of the the screen by the way this is a program a free program called own is 2.5 you can download it Oh cyrix for Mac if your market person no matter market person but it works really good so you can see the fracture here okay and remember the images the sides are reversed this is the right over here this is the left over here LT left 2015 so a little kind of hypoplastic so you might have been born with a little maybe hypoplastic nests here where this was
real brittle and ready to break it's hard to say but we do have a phenomenon here my students should pick that one up pretty quick what do we got going on over here look how thick it is that's stress shielding so biomechanics are completely off that's not surprising he had chronic low back pain all the forces are going through here and this has got you have to be careful this could look like an asteroid asti almost you're not careful but he did they did scintigraphy on him and it
was okay there was no asteroid Ostia woman here let's just stretch it so we got a relatively run-of-the-mill fracture here which could have been the cause of his low back pain I didn't see an MRI for this time so this doesn't really explain why lies getting bilateral leg pain so I mean shouldn't they have done a two level

fusion

I didn't see anything wrong at 4:00 at 4:00 or 5:00 so I'm not sure why they did it to level

fusion

on this patient in the first place you know I
would have never suggested anything like that all right so anyway to level

fusion

was performed after he

failed

all his conservative care and it was an old-school posterior I mean we don't really even do that in this country anymore where they just they roughing up the posterior arch and they they lay down bone chips in hopes that they can fuse the posterior arch well what about the what about the anterior column what about the intervertebral disk you're not gonna stop movement there I
mean these that's why we don't do these

fusion

s anymore but nevertheless this is an old-school an old-world place so no clue why they did they'll four or five I didn't see anything wrong there was no flexion extension studies done so it wasn't unstable that I know of it's a unilateral spondylolysis so I don't know I don't know why they did that but they did it and it was a disaster so after the patient had much more pain especially in his low back and and will
a case of double failed lumbar fusion and dangerously misplaced pedicle screws
perhaps see why but no change in the original leg pains but now he's got a brand new horrible pain on the right anterior thigh a strong burning up burning strong burning type pain miserable 2.5 years he went they wouldn't even do a new CT after the imaging to see what was wrong you know that they should be ashamed of themselves when you see these pictures you'll see what I mean okay so unable to get new imaging so if you did conservative care and just suffered which is ridiculous
they even put him to send him to a psychologist so a septum must be wrong with you but wait they should have just done a new CT and we wouldn't be here but they didn't so treated by a neurologist they thought there's something wrong with his brain his cervical spine thoracic spine everything was checked out and maybe MS but no nothing was there so our rheumatologist no rheumatoid factors everything was fine so finally they ordered a new CT in 2017 they also ordered an EMG NCV study
which was positive for l4 radiculopathy I'm not sure the order which one of these came first but you know then they probably said oh yeah something something has gone wrong here okay so surgeon kept saying there was nothing wrong nothing wrong with the patient EMG was also done everything I said already and well the the surgeon said that

fusion

was a success the first

fusion

let's take a look and see if that was really a success so here is now remember he has burning pain on the right
anterior thigh students what nerve root it's classically not all the time about 75% of the true time or anecdotally this is true what nerver did you suspect with the anterior front of the thigh burning pain l3 right l3 well here you go here's a

pedicle

screw right

pedicle

screw this is an axial view 2017 this one's not too bad it's not sticking out the front at least it's in the

pedicle

but look at this one I mean my fifth quarter students would at this my first quarter
students can look at this and say oh my goodness he's completely missed the target and what lives right exactly where this is that that's from the exiting l3 nerve root comes out and it goes down right in front in this region so he got a gat shish-kebabed by this screw so no wonder he's he has pain on the right anterior thigh it's a perfect

case

I mean this is I mean chiropractic students can figure this out so I don't know what the problem was but after the video according
to the patient they finally said oh something's wrong we better fix this so they did here's a look at the construct on a single CT kind of a scout view we didn't have yeah and then they didn't even do on the CT they didn't even do sagittal images all I got is axial images it was like a like a kind of a half-ass CT scan but it was enough to show the problem and we're not done yet but you can see the CT construct looks good although you can clearly see the better the rod is
bent it's either pulled out or it has nothing to traction into so it's out of place I mean they should have been able to see this on a simple x-ray but already the patient they did nothing okay there's just a little recap of everything I saw right there you know shame on these doctors for not listening the patient shouldn't have taken 2.5 years to do this but we're not done let's go up and look at the

pedicle

screws

at l5 okay so now what's going on well they're
given they went through the bone they went three other side that's a big no-no because you got all sorts of blood vessels on this side the iliac vessels in particular is right here so this image doesn't tell the story what you see the next image I put this one in here because this was a

fusion

to fix the spondylolysis right to fix the broken bone students did they fix the broken bone well there's the stress shielded pars at least they didn't fracture that side no there it is
still fractured it's a fracture right through there so the

fusion

failed

and to assess the

fusion

this should all be white right they put bone chips here they tried to fuse the two segments together with the old-school posterior

fusion

what there's nothing here this is a this is a joke there there's a couple of bone chips floating around we'll see a CT of this too but this is just a complete ridiculous there's no

fusion

here at all these

pedicle

screws

are not designed to be
the

fusion

construct they're like a cast to stabilize the motion segment that's been fused to give this bone this bony pace they put in this bone graft material to give it time to fuse hard as a rock and then that is the

fusion

and not these

screws

on design so they'll they'll break in things like that so here's another cut a little bit higher up now what do you see students I know my students are going home my god what have they've done and they use the

pedicle

screw
that's a way too long for it's not designed for this this is this is unconscionable this can't kill the patient look at that here's the one that's probably the this is one of the iliac art and it's clearly into the iliac vessel it's a pulsatile vessel it can wear out the wall he can get an aneurysm from this he can get a blood clot from this worst of all he could this thing could pop he could bleed out and die so that's that's ridiculous that should have been
caught immediately after the surgery in fact should have been caught during this surgery they're using no stealth technology obviously or no interoperative alarm or they probably had nothing I don't know how they did this but this is completely unacceptable no matter what part of the world you're in I mean you'll kill the patient so yeah that's that's the that's the successful

fusion

which obviously wasn't a success so they called him back in and they fixed it at
least oh here's an MRI no it's 2017 oh yeah there was an MRI 2017 so this is a midsagittal cut between the between the dif

fusion

construct you can't see it's on either side of it but I just wanted to point out you can see the thecal sac coming down like this and you can see up here at 3 it is getting a little a little deformed so there is some stenosis that measured out the thecal sac this dimension here should always be shouldn't ever be less than 10 cent or 10 millimeters
they measured it out to 6.75 I believe was under 7 millimeters that's a severe stenosis and it doesn't look that bad but the reason is he's got short

pedicle

s so he has his moderate i was a moderate to severe central stenosis here could that be responsible maybe it could be responsible but usually not I mean to have leg symptoms usually you have to have two levels of stenosis if this will look the same that one looked the same but just that one level of moderate to severe that's
not severe stenosis it's bad enough to not to block all the cerebral spinal fluid though right this is all epidural fat so it is squeezing it pretty good but I've seen way way worse than this and patients didn't have any complaints at all so I wouldn't have extended the

fusion

up I would have done some flex of Fassett or some selective nerve root box just to confirm try to confirm that this is the problem numbness up with an anaesthetic and see if you can knock some of the
patient's symptoms out you got to prove that this level is the problem before you go in there infuse it I mean and they didn't according the patient they didn't do any of that stuff and I have a lot of gzip probably 20 emails from him so I got the story pieced together pretty good okay there's also a little annular tear some of you have seen there's another thing I wanted to mention oh this is an anecdotal finding but look at the size of these discs what do you think this
a case of double failed lumbar fusion and dangerously misplaced pedicle screws
one's more normal the disc should be about a no more than a third of the height of the vertebral body look at that big thing and that one those are more than half of the size of vertebral body I work for a spine surgeon one time who gave this a name he called it floppy disc there's no research on it but anecdotally he dreaded these these

case

s because the patient's didn't do well they didn't do with the conservative care and they didn't do well with

fusion

either
don't know why that is somebody needs to do a study on that if any of you surgeons out there I write these things up for free I let me use some of my students and it's great learning experience from them I just finished one right now it's in press right now so send me an email if you're interested in writing stuff up but anyway so you know could that be a source of his chronic pain it could be chronic low back pain these typically don't cause leg pain unless it's a
referred pain but annular tear right here HIV is a sign of an annular tear so that could be causing referred pain but probably not all the way down to the bottom of his feet so so it was still kind of a mystery you know he's not a great surgical candidate and that's what gives

fusion

a bad name right if you got to be a perfect candidate for

fusion

if you're gonna try that otherwise you get

case

s like this and it makes

fusion

look terrible does

Fusion

always fail look at Tiger Woods
right now right he had a couple of silly procedures almost like the Peyton Manning story couple silly procedures got an ACDF peyton manning did one is Super Bowl Tiger Woods got a he got a procedure from the front and a lift procedure anterior

lumbar

interbody

fusion

and so far looks good he's swinging the club like the days of old if he was my client by the way I wouldn't like he's asking for trouble but we'll see how long he lasts he should thank his lucky stars he's got as
good as he he's got but we'll see we'll see it's a great story anyway I digress let's get back to the story here so so they finally did this revision surgery and you know as we mentioned it was a joke we said this already or no we didn't say this already we haven't talked about the revision that's why we're here right see I got off on a tangent and forgot what I'm doing so let's talk about the revision we finally after two and a half years he did a
revision surgery so they're gonna take those dangerous medical

screws

out at s1 and at l5 and at l4 so it doesn't rupture his blood vessels and they're gonna maybe reinsert them the correct way and put more bone graft material in so so perhaps he actually has a successful

fusion

and so what happened well here is an M and she sent me so you tell me he this is a there should be two four six there should be six

pedicle

screws

what do you see well I see there's no maybe these came
from the l4 level these came from the l5 level at least they got the dangerous ones out uh-oh there's the rods there's the crossbar so the nuts where's the rest of these

screws

they broke the damn things off inside his s1 segment and they're still sticking out they're not as bad as they all five

screws

thank goodness they got those out but they left them in too long and they broke them off so I mean they should have followed up that in this country this would be a massive
lawsuit but in that country I guess you can't do that so anyway there you go let's take a look and see let's get the the CT scan this is after the the new revision they finally did a CT to see why he's complaining again and by the way now after this revision surgery his pain did go away his his right anterior thigh pain went away now he's got horrible left groin pain on top of the same pain he's had in the back and lick didn't fix any of that but now he's got a
new pain keep that in mind a new pain on his left groin so here's the broken

screws

there's the

screws

going through and there you can see the heads are gone they're broken right off and they're still poking out there's some of the iliac vessels they're not as bad as the five

screws

but I mean that's pretty close to me hopefully he'll be okay with this because I guess they could go in through the front and do some type of procedure although this level is pretty
hard to get to get through to get out from the because the

lumbar

lordosis but yeah and then we look over here you can see it's still sticking out and it's completely broken so not good doctors not good so let's see

fusion

construct they so what do they actually do now here's the surprise the patient didn't even know they did this now they fused l3 and l4 together now I'm not sure why they even did that because if they're thinking central stenosis you don't need
to do a

fusion

you can do just a simple decompression perhaps they thought I think the patient said in the email that they thought that he had a spondylolisthesis or he was unstable here but I mean he's in perfusing there was no indication that he was unstable sometimes he went to get in there during the surgeon they can yank on the spine with her hand and they can feel if the segment so maybe he pushed and pulled on it and fell ooh there's too much instability so I don't know if the
surgeons out there the team you want to fill in the blanks you know put down in the comments what went out I'd love to hear the other side of the story but I don't have a report I don't have anything but nevertheless here we go same surgeon fusing so this one's at least going through the

pedicle

here at least in this cut this is a cut through the right intervertebral foramen so how's the

fusion

look how's this successful

fusion

look down here I this is I don't think
they put new bone chips here if these are the old bone chips I mean it's not it's not fused at all it's been about five months so I know maybe it's a little early maybe these will fuse up with the passage of time if they're new bone chips there's no

fusion

down here they didn't even try to do anything down here they take the

pedicle

screws

out so this is a complete pseudarthrosis there's the fracture still there luckily it hasn't slipped out of place so
that's great but let's now let's turn our attention to this this l3 l4 level make sure didn't miss anything I got everything we said already so here is the l4

screws

so they've successfully took them out and reput they all four

screws

in they look pretty good this IVF is fine it'll get a little close to the top here but usually the the nerve root kind of hangs out above so I don't think that's a problem on the left side here actually that should be the right side
that's not the left that's the right side now from this image you look okay at least they're not sticking out like you know crazy so they got the right size

pedicle

screws

let's take a look at the well here's a they did a 3d reconstruction which is pretty cool pretty modern technique think they would carry that over to their

fusion

technique but you can see all the bone chips that have not fused at all right maybe they will with more time if these are new bone chips I
don't know if these are from the new

fusion

or the old

fusion

and there's absolutely no you can see a couple of bone chips scattered around here between l5 and s1 but yeah that's cut that's a pseudo arthrosis there's no

fusion

there no you can see the new

pedicle

screws

here at three four where's the spinous process here's two there's one there's spinous process of two what's where is it so what they do they did a laminectomy they cut out the spinous
process they cut out most of the lamina and they spared D they spared some of the facet joints so if they're going to do that old-school they could have just done a laminotomy decompression so that's probably why they did the

fusion

so this didn't become unstable I wouldn't recommend it that it would have said tried that probably wouldn't need a little more it for Mayo based on the information I had they should have just tried a simple decompression to see even before that
they should have tried a Selective nerve block and tried to numb up the area you see if the patient he was even a candidate for this

fusion

but no so let's blow it up again here you see the

screws

complete lack of

fusion

here all right now for my students let's see that I'll give you a second take a look at this and see what you can see memories got groin pain now on the left leg growing pain in the left leg is the nuke employee ah some of you saw here we go the same damn mistake
there's a

pedicle

screw that's obviously not in the

pedicle

it's sticking right out into the wind here didn't even hit the

pedicle

so the guy made the same mistake and what nerve root would you suspect is the trouble with a groin problem the l2 nerve root belt earth the answer ramus comes out comes right down here right over here so you got stabbed the l2 nerve root is being got shish kebob by the by this

pedicle

screw that's not in the right place so no wonder he's got
horrible pain on the the inside of his thigh is left groin come on guys the patient that he's not crazy this is makes complete sense to me right and belts and oh yeah some of you saw these two look at those there's the old

screws

that broke off they're definitely out there where the blood vessels are and there's not a good thing all right let's take a look at the CT scan look at this what what in the world did not even close I mean the

pedicle

he didn't even hit the

pedicle

this is through the transverse process so you know the nerve roots come out there right about in this region here the l2 actioning roots and it's completely I mean just hammering the thing so the poor guy okay yeah there's a level again you can ready to put this in here oh you can just see there's no there's no there's no particular pillar right super articular process a fair ticket process it's all gone here so it's a old-school laminectomy all right so you
got to be kidding me right how in the world can they botch another

fusion

exactly the same way well maybe not quite as bad they only botched one out of the four

pedicle

screws

instead of a whole bunch of them but I mean they really botched this one so everything I said it's stabbing the left l2 nerve root so why the patient has a groin pain it's no no mystery that's just to show you the laminectomy again see the posterior arch is completely go on here and spinous is gone I think we
talked about that enough okay they forgot to put bow no the other thing so again the the

fusion

construct or the rods and the

screws

that's not the

fusion

right you got to put bone in here too bonus forever you need to make this one solid block of bone so there should be bone chips all over the place here you can even put them between the transverse processes put them on the back of the lamina fuse all this stuff so the darn thing fuses they didn't I don't see a single bone chip
right these are the bone chips I mean is that one maybe there's one there I don't know what I don't understand this is not designed to be a lifelong deal you don't these can break they will probably fail if you don't have a

fusion

here so Oh anyway let's sum it up so he's got pseudarthrosis all all three levels no not surprising here there's no bone ship Steven to fuse he still got the original problem that unilateral spondylolysis could be a pain generators could
be pain generators he's got a

misplaced

left

pedicle

screw and that's saying it lightly it's completely out of the ballpark and it's shish-kabob een the right that should be the Elco that's right shish kebob means stabbing the left l2 actually nerve root he's got broken

pedicle

screws

at us one still potentially dangerous not as bad as they were thank goodness but they're still not acceptable and now he's got chronic radicular pain for a long time the he describes
pain all over his legs so it's probably now become a neuropathic pain syndrome that's probably even too late to fix this he's getting up getting a spinal cord stimulator maybe that will help him for the leg pain but but the remember when they took out after two and a half years they took out the l5

pedicle

screw that was in the left anterior thigh here the right into your thigh pain so maybe the chance if they remove that

pedicle

screw that's stabbing that l2 nerve root on the
left maybe the chance at least some of that that horrible burning pain and his left groin region will be better so if they need to do a revision and do this right okay he did have a recent EMG which was negative so that's at least a good thing but remember the the sense of the sensitivity and specificity the sensitivity in particulars down in the 60% so just because you have a negative EMG it really doesn't mean anything EMG test if it's positive it's probably positive it's
up in the 80% still not the greatest test in the world so if it's positive it's probably really positive if it's negative it really doesn't mean that it's not negative it's not very good at picking out normals all right recommendations get the heck out of that country get start a GoFundMe page get I don't know how you're going to do it but don't let those people do surgery on you again fly to Germany is pretty close I think or you know get to a more developed
nation with someone who's got skills that are more up-to-date you know fly to this country if you will and you're going after ever revision surgery you've got to have that whole thing taken out and try to do a real interbody

fusion

now decompress up a little bit better and if that doesn't work then you're going to end up with a spinal cord stimulator he's got some cervical problems as well that's why I think he's getting neuropathic pain now he's maybe
he's getting his brain his sensitize he's starting to feel pain where normal people don't feel pain so just a really sad story but we all I'm sure wish him good thoughts and a positive vibes right hopefully he'll come out of this and these he'll get the proper medical care but okay so I hope you have enjoyed the video and I have another crazy

case

coming I don't know what it is about crazy

case

s and that one's coming in the future and you're gonna I've
never seen anything like this the spine that you're gonna see that even in textbooks oh it should be quite interesting so hope you enjoyed the video we'll see in the next one