{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,30]],"date-time":"2025-10-30T11:29:39Z","timestamp":1761823779453},"reference-count":14,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["SPI"],"published-print":{"date-parts":[[2016,4]]},"abstract":"\nOBJECT<\/jats:title>\nAs spinal fusions become more common and more complex, so do the sequelae of these procedures, some of which remain poorly understood. The authors report on a series of patients who underwent removal of hardware after CT-proven solid fusion, confirmed by intraoperative findings. These patients later developed a spontaneous fracture of the fusion mass that was not associated with trauma. A series of such patients has not previously been described in the literature.<\/jats:p><\/jats:sec>\n\nMETHODS<\/jats:title>\nAn unfunded, retrospective review of the surgical logs of 3 fellowship-trained spine surgeons yielded 7 patients who suffered a fracture of a fusion mass after hardware removal. Adult patients from the West Virginia University Department of Orthopaedics who underwent hardware removal in the setting of adjacent-segment disease (ASD), and subsequently experienced fracture of the fusion mass through the uninstrumented segment, were studied. The medical records and radiological studies of these patients were examined for patient demographics and comorbidities, initial indication for surgery, total number of surgeries, timeline of fracture occurrence, risk factors for fracture, as well as sagittal imbalance.<\/jats:p><\/jats:sec>\n\nRESULTS<\/jats:title>\nAll 7 patients underwent hardware removal in conjunction with an extension of fusion for ASD. All had CT-proven solid fusion of their previously fused segments, which was confirmed intraoperatively. All patients had previously undergone multiple operations for a variety of indications, 4 patients were smokers, and 3 patients had osteoporosis. Spontaneous fracture of the fusion mass occurred in all patients and was not due to trauma. These fractures occurred 4 months to 4 years after hardware removal. All patients had significant sagittal imbalance of 13\u201315 cm. The fracture level was L-5 in 6 of the 7 patients, which was the first uninstrumented level caudal to the newly placed hardware in all 6 of these patients. Six patients underwent surgery due to this fracture.<\/jats:p><\/jats:sec>\n\nCONCLUSIONS<\/jats:title>\nThe authors present a case series of 7 patients who underwent surgery for ASD after a remote fusion. These patients later developed a fracture of the fusion mass after hardware removal from their previously successfully fused segment. All patients had a high sagittal imbalance and had previously undergone multiple spinal operations. The development of a spontaneous fracture of the fusion mass may be related to sagittal imbalance. Consideration should be given to reimplanting hardware for these patients, even across good fusions, to prevent spontaneous fracture of these areas if the sagittal imbalance is not corrected.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2015.7.spine15153","type":"journal-article","created":{"date-parts":[[2015,12,18]],"date-time":"2015-12-18T15:17:19Z","timestamp":1450451839000},"page":"639-643","source":"Crossref","is-referenced-by-count":9,"title":["Fracture of fusion mass after hardware removal in patients with high sagittal imbalance"],"prefix":"10.3171","volume":"24","author":[{"given":"Cara L.","family":"Sedney","sequence":"first","affiliation":[{"name":"Departments of Neurosurgery and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Scott D.","family":"Daffner","sequence":"additional","affiliation":[{"name":"Orthopaedics, West Virginia University, Morgantown, West Virginia; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jared J.","family":"Stefanko","sequence":"additional","affiliation":[{"name":"Spectrum Orthopaedics, Inc., Canton, Ohio"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hesham","family":"Abdelfattah","sequence":"additional","affiliation":[{"name":"Orthopaedics, West Virginia University, Morgantown, West Virginia; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sanford E.","family":"Emery","sequence":"additional","affiliation":[{"name":"Orthopaedics, West Virginia University, Morgantown, West Virginia; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John C.","family":"France","sequence":"additional","affiliation":[{"name":"Orthopaedics, West Virginia University, Morgantown, West Virginia; and"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"Suppl 6","key":"b1-spine15153","series-title":"Eur Spine J","doi-asserted-by":"publisher","first-page":"S853","DOI":"10.1007\/s00586-013-3024-x","article-title":"Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure","volume":"22","author":"Berjano","year":"2013"},{"key":"b2-spine15153","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"1643","DOI":"10.1097\/01.brs.0000169451.76359.49","article-title":"Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis","volume":"30","author":"Glattes","year":"2005"},{"key":"b3-spine15153","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"E158","DOI":"10.1097\/01.BRS.0000058951.16468.24","article-title":"Bilateral pedicle stress fracture after instrumented posterolateral lumbar fusion: a case report","volume":"28","author":"Ha","year":"2003"},{"key":"b4-spine15153","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"E137","DOI":"10.1097\/BRS.0b013e3181b7ac6a","article-title":"Vertebral compression fracture in the middle of fused segments without a history of injury: a case report","volume":"35","author":"Ha","year":"2010"},{"key":"b5-spine15153","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"E551","DOI":"10.1097\/BRS.0b013e3181f3516d","article-title":"Late stress fracture of a well-consolidated strut graft after total spondylectomy in the thoracolumbar spine","volume":"36","author":"Ito","year":"2011"},{"issue":"22 Suppl","key":"b6-spine15153","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"S165","DOI":"10.1097\/BRS.0b013e31826d62c9","article-title":"Frequency, risk factors, and treatment of distal adjacent segment pathology after long thoracolumbar fusion: a systematic review","volume":"37","author":"Kasliwal","year":"2012"},{"key":"b7-spine15153","series-title":"Br J Neurosurg","doi-asserted-by":"publisher","first-page":"252","DOI":"10.3109\/02688697.2013.835369","article-title":"Analysis of the incidence and risk factors for the progression of proximal junctional kyphosis following surgical treatment for lumbar degenerative kyphosis: minimum 2-year follow-up","volume":"28","author":"Lee","year":"2014"},{"issue":"6 Suppl","key":"b8-spine15153","series-title":"Spine (Phila Pa 1976)","doi-asserted-by":"publisher","first-page":"S190","DOI":"10.1097\/00007632-199106001-00003","article-title":"The effect of spinal implant rigidity on vertebral bone density. 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