Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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The patient came to the clinic 13-January-2013 complaining of
LBP with left sciatica after falling down 12
days ago. The patient is a known hypertensive
for 27 years and stinting was done 6 years ago.
MRI lumbar spine done 13-January-2013 (bad
quality) showing fracture L1 and L3 with
extruded disc L4-5. The patient was walking
bended anteriorly. SLRS was 70 degrees both
sides with pain in the left with no neurologic
deficit. The patient was treated conservatively.
The patient then came 19-February-2013 claiming
that she is deteriorating with LBP and bilateral
sciatica more the left. The lumbar corset was
annoying her, for what she refused to wear it.
There is weak dorsiflexion right foot 4/5. The
patient was sent for further investigations.
MRI lumbar spine done 20-February-2013 showing
further collapse of L1 and L3, extruded disc
L4-5 and severe lumbar canal stenosis L2-3, L3-4
with spondylolisthesis L5-S1. Bone density scan
confirmed the presence of severe osteoporosis.
L2,3,4 and partial of L5. Foraminotomy both L4
and L5 roots. Inspection of L4-5 disc revealed
that it is hard in consistency and not causing
problems, for what it was lift in place without
violation. The fractured L3 body was inspected
and the collapse was more from the right side.
Insertion of the Tsunami Medical inserter was
very difficult mandating that the fracture was
very old and sclerotic. The balloon was inflated
for 4 ml with minimal reduction over 350 Bar.
Considering these data, no attempt was done to
insert the balloon from the left side. Insertion
of the balloon from the right side of L1 showed
acceptable reduction and 5 cc vertebroplasty
bone cement was inserted. Another balloon was
inserted to the left side of L1 and about 8 cc
of liquefied cement was inserted with ease.
Inspection by the C-arm showed that the material
gone with the intraossal veins reaching the
central veins of the 2 above vertebrae.
Considering this fact further 5 cc of more
resilient cement was inserted to the left side
of the L1 body. All stages of surgery were done
using C-arm control.
Routine closure of the wound.
Smooth postoperative recovery.
The liquefied cement slipped inside the intraossal veins
2 level above and one level below.
The patient has several problems, which needs
correction. The main problem was the lumbar
canal stenosis which was resolved. The extruded
disc of L4-5 was hard in consistency and
contained, for what in was not violated, for the
advantage of the patient. The recent fracture of
L1 was expandable, but the old one of L3 was
sclerotic and marble-like in consistency.
In the future it is better to distinguish the
old and recent fracture in osteoporosis. The old
sclerotic one will not be corrected by
kyphoplasty ballooning as in the L3 body.
The cement must not be given when it is still in
liquid form, because it will escape through the
rich venous structures inside the bone elements.
The patient progressed severe weakness of the
left iliopsoas and left quadriceps muscle with
anaesthesia of the left anterior aspect of the
thigh. The patient was inspected immediately
after regaining of the pictures confirming the
intraossal slippage of the cement, inspection of
the epidural spaces was done to rule out any
compression or presence of the cement inside the
canal. It could be inside the running epidural
veins, which is impossible to visualize.
The neural injury is mostly a chemical and
vascular one involving the left D12, L1 and L2