Identifying Surgical Hardware Failure
Written by: James Demetrious, DC, DABCO – Diplomate, American Board of Chiropractic Orthopedists
Patients seek chiropractic care, having previously undergone surgical interventions with and without implanted spinal hardware. This cohort of patients can receive substantial relief through chiropractic care of persistent and worsening symptoms. It is requisite that chiropractors carefully assess those patients for neurologic degradation, spinal instability, and hardware failure.
In their paper published in the International Journal of Spine Surgery, Anand et al. reported a prevalence of clinically significant hardware failure needing revision as low as 3.04%. In their cohort, reflected failures were characterized as broken screws, rod fractures, loose screws, and nonunion. 
A Remarkable Case
The following images were sent to me by a chiropractic colleague to share in my continuing education coursework. One can clearly see the implanted Harrington rod dissociated from its vertebral body anchor screws having migrated caudally.
Our astute chiropractic colleague referred the patient back to the original spinal surgeon, who recommended no further intervention or revision.
For those patients who have undergone spinal surgical interventions and deformity correction utilizing hardware, chiropractic physicians should review available post-surgical imaging and order new studies to identify abnormalities. The American College of Radiology offers the following recommendations:
“Radiography is complementary to MRI and/or CT imaging and is helpful to evaluate alignment and hardware integrity in patients with new or progressing symptoms and previous lumbar fusion. Upright radiographs provide useful functional information about axial loading. Flexion and extension radiographs can be used to look for abnormal motion/increased dynamic mobility .” 
Possible Considerations and Insight
I would agree with the ACR recommendations. Plain film radiography is incredibly important in the assessment of post-surgical patients. Additional imaging studies may be necessary. In practice:
- I order upright imaging studies with flexion and extension stress views.
- If x-rays provide evidence of hardware failure, I may recommend CT evaluation, including sagittal and coronal reconstruction use.
- If there is neurologic degradation, I may request MRI evaluation with a STIR Fat-Sat sequences to provide increased conspicuity of periarticular and neural element edema. I may order a contrast-enhanced MRI study if the surgical intervention has occurred within 12-18 months and the patient has no renal compromise or other contraindications.
As spinal experts and specialists, chiropractors provide invaluable and beneficial care to patients. Post-surgical patients respond well to chiropractic care. It is of vital importance that all physicians assess post-surgical patients carefully, perform and interpret advanced imaging, offer supportive care, and make appropriate neurosurgical referrals when necessary.
- Hutchins et al.American College of Radiology ACR Appropriateness Criteria® Low Back Pain. Revised 2021.
The views and opinions expressed in this presentation are solely those of the author. We offer this only to educate and inform.
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