An 85-year-old male patient, who had been bedridden for two months, presented with a chief complaint of back pain and bilateral lower limb radiculopathy. Diagnostic imaging revealed an osteoporotic compression fracture of the L2 vertebral body, accompanied by severe spinal stenosis at the L4-L5 level (fig.1 & 2). The patient’s prolonged immobility, compounded by severe pain, had precipitated the development of a chest infection, further exacerbated by his persistent decubitus position over the preceding weeks.
Clinical Evaluation and Multidisciplinary Approach
The complex clinical presentation of the patient necessitated a multidisciplinary management strategy, involving discussions regarding the most appropriate therapeutic interventions. One potential approach considered was vertebroplasty for the L2 vertebral fracture, in combination with epidural steroid injections for the L4-L5 stenosis, both to be performed under local anesthesia. However, given the presence of motor weakness (muscle power 4/5) in both lower limbs and the significant severity of the spinal stenosis, the potential efficacy of epidural steroids was regarded with skepticism.
An alternative intervention involved vertebroplasty in conjunction with surgical decompression of the L4-L5 spinal canal under general anaesthesia. However, due to the patient’s significant comorbidities, particularly an active lower respiratory tract infection, the use of general anaesthesia was deemed high-risk. In addition, such a decision carried the potential for necessitating postoperative ventilatory support, further complicating the clinical course. Spinal anaesthesia was considered as a safer alternative, though performing the procedure with the patient in an awake prone position posed logistical challenges, particularly with respect to patient tolerance and respiratory mechanics. Furthermore, prone position poses difficulty in intubation in case of an emergency need.
After thorough consultation with the anaesthesia team, it was determined that the most viable surgical approach would be to position the patient in the left lateral decubitus position. This positioning reduced the respiratory risk profile, though it presented several technical challenges related to altered three-dimensional orientation, instrument handling, limited visibility of the surgical field, and modifications in intraoperative radiographic assessment.
Surgical Procedure
Stage 1: Vertebroplasty was performed on the L2 vertebral body using local anesthesia in standard prone position. One of the rare but serious complication of vertebroplasty is cement leakage into the spinal canal which needs immediate decompression surgery if associated with neurological deficit. Hence, spinal anaesthesia is not advisable for vertebroplasty as immediate neurological assessment is not possible. Post-procedure, neurological examination revealed no deterioration.
Stage 2: The procedure was performed under spinal anaesthesia, with the patient positioned in the left lateral decubitus position. Adequate padding was applied over the patient’s bony prominences to prevent pressure injuries (fig.3). Decompression of the L4-L5 spinal stenosis was performed through a posterior midline approach. Standard instruments and techniques were utilised (fig.4). The operative table was tilted to achieve a sloppy lateral position when dealing with the lateral recess stenosis. Surprisingly, the surgical field was much better than in standard prone position as gravity played a major role in clearing the field of oozing blood. Adequate decompression of dura and nerve roots achieved. Wound closed in standard fashion after thorough haemostasis.
Postoperative Management and Outcome
Postoperatively, the patient tolerated the procedure well and was gradually mobilized with appropriate assistance. His recovery was closely monitored, and he received intensive rehabilitation, including chest physiotherapy, as part of the management plan for his respiratory infection. Additionally, appropriate medical therapy was administered to address the underlying respiratory infection. The patient made gradual progress and was eventually discharged with ongoing outpatient follow-up.
Conclusion
This case highlights the complexities involved in managing elderly patients with osteoporotic vertebral fractures, spinal stenosis, and concomitant comorbidities. A tailored, multidisciplinary approach, involving careful consideration of the risks associated with anaesthesia and positioning, was crucial to the successful management of this patient. The combined use of vertebroplasty and surgical decompression, performed under loco-regional anaesthesia in a left lateral position, proved to be an effective and safe strategy for alleviating the patient’s symptoms while mitigating respiratory risks.
Fig.1: T2 sagittal MR image showing vertebral compression fracture of L2 and severe stenosis at L4-5 level
Fig.2: T2 sagittal and axial MR images showing severe stenosis of L4-L5 level
Fig.3: Patient in lateral decubitus position, strapped onto the operating table with adequate padding
Fig.4: Decompression surgery in lateral decubitus under spinal anaesthesia
Fig.5: Postoperative x-ray – showing post vertebroplasty status in L2 vertebra and decompression at L4-5 level
KAUVERY SPINE INSTITUTE
Dr. G. Balamurali
Chief Consultant and Head of Spine Surgery
Dr. S. Somasundar
Consultant Orthopaedic Spine Surgeon
Dr. Mohamed Najibullah
Consultant Anaesthetist
Dr. Mirunaalini Thangavelan
Dr. P. Keerthivasan