54 A 45-year-old man who had a previous L5-S1 fusion continued to have mechanical back pain a few months postoperatively. Workup demonstrated nonunion. He is without neurologic deficit. Five months after his initial posterior surgery, the graft failed to be incorporated (Fig. 54-1). This indicates nonunion. Nonunion An anterior lumbar interbody fusion (ALIF) was done (Fig. 54-2). The patient’s previous cage was removed and then replaced with bilateral cages containing bone morphogenetic protein (BMP). The question of whether to fuse a patient from the front or the back has been a source of debate. If the pathology is posterior (a migrated disc fragment, facet hypertrophy, lateral recess stenosis), the recommended approach is posterior. This approach is also preferred if the patient has had abdominal surgery, has severe atherosclerosis, or is a male of reproductive age. If the patient has already had a posterior surgery, an anterior approach is preferred to avoid scarring, augment a fusion, or address vertebral body pathology. In this case, we weighed the options of redo posterior fusion, ALIF, or a pain procedure (such as morphine pump). Because the patient had a previous posterior approach, anterior fusion was chosen. A pain procedure could be considered if there wasn’t a structural pathology that could be improved safely through surgery. In this case, an ALIF with BMP in a cage was performed with success.
Mechanical Back Pain with Previous Posterior Fusion
Presentation
Radiologic Findings
Diagnosis
Treatment
Discussion
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