Case Study: Management of L5 Vertebral Pathological Fracture

with Collapse and Lumbar Canal Stenosis L3-S1

A 70-year-old female who presented with a chief complaint of lower back pain. She was an active person and felt something “pop” in his lower back. A couple of weeks later she fell and the following day started having back pain.  

The pain has been getting progressively worse, especially while sitting in a hard chair or driving.  It is relieved in the reclining position. The pain radiates down his right leg and is not associated with any numbness or tingling in his lower extremities. He wears a lumbar- support belt during the day. He denies any recent fever, bowel, or bladder changes.

The patient is in remission from rectal cancer treated with surgery, radiotherapy, and chemotherapy. Imaging was done which showed a fracture of the L5 vertebra and severe stenosis at L3/4 and LS/S1 with severe neuro-foraminal disease and degenerative changes in the spine.

The patient is calm, conscious, cooperative, and well oriented to time, place and person. Upon examination of the lumbar spine, the patient is tender to palpation over the paraspinal musculature. There is tenderness over the spinous process of L5 but has no crepitus with ranging. 

There is a paravertebral muscle spasm. bilaterally around the L5 region. They have a limited range of motion of the spine due to discomfort. The straight leg raise test is positive at 60 degrees. There is no tenderness to palpation over the trochanteric bursa and hip. The patient walks with an antalgic gait.

There is no soft tissue swelling and ecchymosis. The patient has a full range of motion of the hips. The hips are stable on the examination. There is 5/5 strength in bilateral lower extremities and there is no neurovascular deficit distally. There are no erythema, warmth, or skin lesions present. The examination of bilateral upper extremities revealed no neurovascular deficit.

X-ray of LS spine in AP and Lateral views showing significant compression fracture L5 X-ray of LS spine in AP and Lateral views showing significant compression fracture L5 2

X-ray of LS spine in AP and Lateral views showing significant compression fracture L5.

The lower back pain was worsening and aggravated with sitting, standing, and moving. There was pain and numbness in the right lateral and posterior thigh (right  LS-S1 radiculopathy). A CT and MRI were done as a part of the workup.

CT suggested a severe compression fracture of L5 with mild retropulsion of superior endplate. Multilevel degenerative spondylosis of the lumbar spine. Moderate to severe spinal canal stenosis at L3-L4 and L4-L5 levels.

MRI lumbar spine suggested acute or subacute compression fracture at L5. Degenerative changes with multilevel spinal canal or neural foraminal, subarticular recess stenosis were also present at L4-5 and L5-S1.

MRI showing Sagittal Section of Lumbar Sacral Spine

MRI showing Sagittal Section of Lumbar Sacral Spine.

MRI showing Axial Section

MRI showing Axial Section.

All findings were discussed with the patient, as well as treatment options. We discussed the need for biopsy to confirm the diagnosis, as it may impact his future course of treatment with regards to the malignancy. 

Haemotologist and Oncologist consultations were obtained. Treatment options in the form of decompression of the spine, fixation, and fusion were discussed at length with the patient.

Management regarding open biopsy, decompression, and stabilization, its risks, complications, and recovery were discussed at length with the patient. We discussed the procedure and its risk of bleeding, infection, non-union, failure of hardware, need for repeat surgery, chances of temporary or permanent nerve or vessel injury, risk of blindness, cardiac event, stroke, paralysis, and death. We discussed the use of implants in the form of screws and rods.

The patient agreed with the plan of Decomp L3-S1, separation surgery, Pedicle screw fixation, and posterolateral fusion L4-S1 using local autograft and cancellous chips and bone allograft. 

Transpedicular histopathology was sent from the left L5 body, transpedicular. The patient was taken to the operating room where generaI anesthesia was induced. A Foley catheter was passed. Needles for neurophysiological monitoring in the form of EMG, somatosensory monitoring as well as pedicle screw stimulation was done.

The patient was turned prone onto a well-padded Jackson table and positioned appropriately. The bony landmarks were all appropriately padded. The patient was secured to the operating table. The surgical area. was cordoned using 10 x 10 sticky drapes. The back was cleaned with alcohol and painted with DuraPrep.  Aseptic draping was performed with Ioban. 

A surgical incision was marked using bony landmarks from L3-S1. Preop antibiotic was given preoperatively. A time-out was called and the correct patient, correct procedure, and correct site were identified. The laminae of L4-S1 were reached through sharp dissection. Hemostasis was achieved. The posterior elements were exposed using Bovie on the respective sites. 

The lamina of L5 was marked and a Woodson was passed into the lamina of L4 and a C-arm picture was taken to confirm our levels. After confirmation of levels. further dissection was carried out to the facet joints of L3-L4 from L4-L5  and  L5-S1.

The capsules of neither of the joints were reached. Transverse processes of L4, L5 & sacral ala were exposed with dissection, and hemostasis was achieved. The lateral gutters were packed and our attention was drawn towards the laminectomy. Misonix ultrasonic bone cutter was used to perform laminectomy of L4 and L5. 

Further neutral and foraminal decompression was done using Kerrison #3 and #4 for L4, L5 & S1 on both sides. Incidental durotomy (Dural tear)  was found on the left side from a bone spike of  L4. After decompression the durotomy was cordoned and repaired primarily using Prolene  6-0. 

After achieving successful decompression from L4-S1, the inferior lamina of L3 was cut, Hypertrophic ligamentum flavum was removed using Kerrison #4. The repair was covered with a muscle patch followed by Duraseal and Surgicel in layers put to protect the dural repair.

Now the pedicle screws for the S1 were planned and the pedicle of S1 was probed from either side and checked under C-arm. After finding an acceptable position. The pedicle screw of 6 mm x 45 mm cortical fix screw was put on both pedicles of S1. 

The pedicles of  L5 were cannulated now and the position of the probe was checked under the C-arm and found to be acceptable and biopsy material was sucked out using a Jamshidi needle from the right pedicle of LS. Some tissue and bone marrow aspirate was sent for biopsy. A 6 mm x 40 mm cortical fix screw was inserted on both pedicles of L5. 

The pedicles of L4 were cannulated similarly  and checked under C-arm and found to be acceptable. A 6 mm x 45 mm cortical fix screw was inserted on both pedicles of L4. The screw heads were lined well on both sides. The wound was washed copiously with normal saline mixed with Bacitracin and gentamicin.

Decortication of transverse processes and the facets of L4–S1 were performed and the gutters were packed with a bone graft which was a mix of local autograft and allograft bone chips. 

The screws were lined and rods were placed on both sides and tightened to the screw heads. The final pictures of the screw were taken with C-arm and saved. Hemostasis was achieved. Vancomycin antibiotic was sprinkled into the wound. Considering the durotomy a deep suction drain was not put. The closure was done in layers.  Two suprafascial drains were put. The counts were completed, checked, and correct at the end of the procedure. The patient was transferred into a supine position on the bed, extubated, and moved to the postoperative care unit in a stable condition.

Intraoperative fluoroscopy images Intraoperative fluoroscopy images 2

Intraoperative fluoroscopy images.

Postoperative X-ray showing AP and Lateral Views   Postoperative X-ray showing AP and Lateral Views 2

Postoperative X-ray showing AP and Lateral Views.

At six months post-op she has been living at home by himself, taking care of his dog, driving and doing activities of daily living well. He has been recovering well. He is able to walk unaided. He has been doing outpatient physical therapy. He is working out at home also. Denies headache, fever, chills, radiation, tingling, numbness, weakness.

Her pain and radiation on the right lower extremity have recovered. He plans to get more active.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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00:52 30 May 23
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I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
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19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
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15:02 02 Mar 23
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21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
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20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
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16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
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21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
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19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
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23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
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17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
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19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
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19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
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19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
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03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
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22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
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02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
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14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.