Nagamma [name changed], an 85-year old lady presented on a stretcher. She was in excruciating pain and was unable to even get up to take care of her basic needs of day-to-day life. Best effort to help her was undertaken by spine surgeon Dr. Yogesh K. Pithwa of Sattvik Spine Foundation.

On detailed history, it was noted that the patient had sustained a trivial fall 1 month back following which she developed progressive myelopathy with inability to walk due to paraparesis with involvement of bladder and bowel. As a result, she was unable to control her urine and motion. Her radiographs [fig 1] and MRI [fig 2] revealed osteoporotic collapse of L1 vertebra with signal intensity changes suggestive of edema [arrow] in conus medullaris. Due investigations were carried out to rule out any pathological nature of the fracture. This included blood investigations and a close perusal of MRI images. BMD [bone mass densitometry] of the spine revealed a “T” score of -3.0 indicating osteoporosis.

Presentation Radiograph Showing The Collapsed Vertebra

Presentation Radiograph Showing The Collapsed Vertebra

Presentation MRI showing the severe compression of spinal cord with consequent myelomalacia indicating severe damage

Presentation MRI showing the severe compression of spinal cord with consequent myelomalacia indicating severe damage

Post surgery radiographs showing the successful execution of surgical plan

Post surgery radiographs showing the successful execution of surgical plan

Post surgery CT scan showing satisfactory decompression of the spinal cord

Post surgery CT scan showing satisfactory decompression of the spinal cord

In view of myelopathy, surgical decompression of the spinal cord was absolutely essential. However, her osteoporosis posed a challenge for surgical fixation of the fractured spine. After due discussion of treatment options, surgery was carried out with insertion of pedicle screws into two normal vertebrae above and below. Strength of the construct was augmented by using cross-links [line arrow] at both ends, cranial and caudal. Further augmentation of the construct was carried out by inserting sublaminar wires [block arrow] at the extremes of the construct so as to improve the pullout strength [fig 3 & 4]. Safe and satisfactory decompression was achieved by bilateral transpedicular decompression at L1 level [postop CT-fig 5]. This method of decompression prevented any undue manipulation of the neural structures at this stage and hence, prevented any kind of deterioration in her nerve function.

Though challenging, appropriate use of multiple surgical techniques can still yield satisfactory outcome in such difficult cases. Best outcomes in spine surgery can be achieved by meticulous attention to all aspects of patient care.