Case 1: A 49-year-old female had received living donor liver transplantation (LT) for acute-on-chronic liver failure (ACLF) ten years prior to presentation (Table). The patient complained of low back pain and leg pain, which had not responded to drug therapy for two years. She presented with radicular pain from her buttock to her left leg, and significant decrease in walking capacity. The lateral lumbar radiograph showed a significant instability at L3/4 and L4/5 disc levels with degenerative spondylolisthesis (Fig. 1). On magnetic resonance imaging (MRI), disc degeneration with disc bulging was found at the L3/L4, L4/L5, and L5/S1 disc levels (Fig. 2). Spinal stenosis was found at the L3/L4 and L4/L5 disc levels (Fig. 2), and foraminal stenosis was identified at the left L5/S1 foramen.
The patient underwent lateral lumbar interbody fusion (LLIF) at L3/4 and L4/5, followed by posterior lumbar interbody fusion (PLIF) at L5/S1 and supplemental percutaneous posterior instrumentation (Fig. 3). First, the LLIF procedure was performed as previously reported[12] with some modification. Briefly, the patient was placed in a left lateral decubitus position, with the skin incision (5 cm) between L3/4 and L4/5. Following the dissection of abdominal muscles, the retroperitoneal space was assessed by blunt dissection. The peritoneal content and ureter were safely mobilized anteriorly without adhesion with the surrounding tissue. The psoas muscle was identified, and intervertebral discs (L3/4 and L4/5) were exposed by dissecting the psoas muscle from 1 cm posterior from the anterior edge of the psoas muscle. After curettage of the disc tissues, appropriately-sized LLIF cages were inserted. An Hydroxyapatite/Collagen (HAp/Col) composite[13] (Refit®, HOYA, Japan) absorbed on autologous bone marrow aspirate (BMA) was packed into the cages. Next, a mini-open PLIF at the L5/S1 level was performed, and pedicle screws were then inserted into the L3, L4, L5 and S1 levels percutaneously and titanium alloy rods were placed (Fig. 3A, B). The operation time was 336 minutes (lateral: 122 minutes, posterior: 214 minutes) and intraoperative blood loss was 109 ml. Seven days following surgery, the levels of aspartate transaminase (AST) and alanine transaminase (ALT) increased to 249 IU/L and 214 IU/L, respectively. The lactate dehydrogenase (LDH) level was also increased to 388 IU/L. Contrast computed tomography (CT) images identified neither blood flow disturbance nor morphological abnormality on the transplanted liver. Drug-induced hepatopathy or liver allograft rejection was suspected. Although the use of all drugs, including antibacterial agent and analgesic, was stopped, serum levels of AST, ALT, and LDH continuously increased to 474 IU/L, 574 IU/L and 510 IU/L at ten days postoperative, respectively. Therefore, a liver biopsy was performed. A mild cellular rejection of liver tissue was diagnosed by histopathological examination; however, it was not equivalent to the clinical course of a severe liver disorder by liver allograft rejection. The serum level of these three enzymes rapidly increased and reached peak levels at 14 days following surgery (AST: 832 IU/L, ALT: 1473 IU/L, LDH: 602 IU/L). After prohibiting taking acetaminophen as needed, those serum levels gradually decreased and reached normal ranges 50 days following surgery (AST: 25 IU/L, ALT: 19 IU/L, LDH: 155 IU/L). Two months following surgery, leg symptoms and low back pain were significantly improved. Sagittal CT images taken two years following surgery showed irregular bridging bone through the LLIF cage at L3/4 and L4/5, and robust bridging bone through the L5/S1 intervertebral space (Fig. 3C). The patient could walk without recurrence of leg pain 2.5 years following surgery.
Case 2: A 66-year-old female, who had received a living donor LT for hepatocellular carcinoma (HCC) six years prior (Table), presented with back pain after a fall. Two months after the injury, she experienced a gradual decrease of muscle strength in her lower extremities and was diagnosed with late-onset paralysis resulting from a T12 vertebra fracture. Her muscle strength in the lower extremities were significantly decreased (Manual muscle test [MMT]: iliopsoas 3/3, quadriceps 3/3, tibialis anterior 1/1, extensor hallucis longus 1/1, gastrocnemius 2/2). CT images showed a severe collapse of the T12 vertebra (Fig. 5A), and a bone fragment of the T12 posterior wall displaced into the spinal canal (Fig. 5B). MRI showed the collapsed T12 vertebra with T1 – weighted image (WI) low and T2 – WI partial high, and the displaced T12 posterior wall compressing the spinal cord (cauda equine) (Fig. 5B, D).
The patient underwent posterior instrumentation surgery followed by T12 corpectomy using a wide-foot print expandable cage (X-core, NuVasive, Inc.) (Fig. 6A, B). First, pedicle screws were inserted into the T10, T11, L1 and L2 vertebrae bilaterally, and a Titanium alloy rod was placed for alignment correction and distraction of the T12 vertebra collapse. Next, the patient underwent retropleural exposure for a T12 corpectomy using a wide-foot print expandable cage (X-core, NuVasive, Inc.) as previously reported[9]. Briefly, the patient was placed in the left lateral decubitus position with the skin incision along the left T10 rib. After removing a small segment (7 cm) of rib, the T12 vertebra was safely exposed through a retropleural approach without adhesion with the surrounding tissue. By using an expandable retractor (MaXcess®, NuVasive, Inc.), the T12 vertebral body replacement was performed by a wide-footprint expandable Ti cage (XCore®, NuVasive, Inc). Autograft (removed rib) with hydroxyapatite/type I collagen (HAp/Col) composite[13] was packed inside and outside the cage. The operation time was 360 minutes, and intraoperative blood loss was 133 mL. Following surgery, no complications associated with the transplanted liver were identified.
Sagittal reconstruction CT images taken two years following the spinal surgery revealed robust bridging bone inside and outside of the cage (Fig. 6C). Her muscle strength in the lower extremities were significantly improved, and she could walk without a cane 2.5 years following spinal surgery.
Table Patient’s characteristics
Case
|
#1
|
#2
|
Age
|
49
|
66
|
Gender
|
Female
|
Female
|
Diagnosis of liver disorder
|
Acute-on-chronic liver failure
|
Hepatocellular carcinoma
|
Immunosuppressant drug
|
Cyclosporine
|
Tacrolimus Hydrate
|
Spinal disorder
|
Degenerative lumbar disease
|
T12 vertebral fracture
|
Spine surgery
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LLIF (L3/4, L4/5), PLIF (L5/S1), L3-S1 Instrumentation
|
T12 corpectomy, T10-L2 instrumentation
|
Follow-up
|
27 months
|
31 months
|
Complication
|
Transplanted liver dysfunction
|
None
|
LLIF: lateral lumbar interbody fusion, PLIF: posterior lumbar interbody fusion.