Correction of vertebral pseudoarticulation: An unusual driver of adult sagittal and coronal plane deformity

Abstract

Background:

A 58-year-old female with a history of L2-5 fusion at an outside institution presented with 9 months of mechanical back pain, inability to achieve upright posture, subjective lower extremity weakness, and pain when ambulating. Imaging demonstrated proximal junctional failure (PJF) with resulting sagittal and coronal plane defects secondary to the formation of an L1/2 vertebral pseudoarticulation.

Case Description:

Surgery was undertaken to revise and extend the previous construct from T10-ilium. After subperiosteal exposure and pedicle screw replacement, left L5 laminectomy and L5-S1 total lumbar interbody fusion were performed to maximize lumbosacral lordosis. An L1/2 revision laminectomy was performed, and the disc space was distracted with laminar spreaders to reduce the pseudoarticulation. Deformity correction was finally achieved with a 4-rod construct and placement of a proximal tether to prevent recurrence of proximal junctional kyphosis (PJK). The patient recovered well initially, with maintained alignment at 6-month follow-up. At 7 months, multiple falls precipitated the development of PJK, necessitating rostral extension of the construct. Further falls led to unilateral rod fracture and loosening of pelvic pedicle screws. Another revision was performed, replacing the rod and upsizing the pelvic screws, achieving a favorable structural outcome.

Conclusion:

Pathology of the uppermost instrumented vertebra is a recognized complication of spinal fusion. It can manifest as PJK or progress to PJF, in which kyphosis is accompanied by structural or instrument failure with symptoms requiring surgical revision. Presentation is variable, and reoperation requires an individualized approach. This case demonstrates the challenges inherent to adult spinal deformity surgery.

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Video Annotations[1-8]

0:01 – Clinical presentation

1:55 – Risks and benefits of procedure

2:04 – Surgical planning and necessary equipment

2:40 – Surgical video

7:03 – Postoperative imaging

7:19 – Disease background

8:18 – Clinical and radiographic outcomes

Ethical approval:

The Institutional Review Board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Video available on:

https://doi.org/10.25259/SNI_1344_2025

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