Letter to the Editor on: “Sterile Seroma Resulting from Multilevel XLIF Procedure as Possible Adverse Effect of Prophylactic Vancomycin Powder: A Case Report” (Evid Based Spine Care J 2014;5(2):127–133)

The case published by Youssef et al is highly interesting in my opinion, but not for what the presentation focuses on but rather for what it omits.1 The preoperative lumbar sagittal alignment (Fig. 2) is rather nice with 50 degrees from T12 to S1, despite the severe degenerative changes that led to the indication for surgery. The postoperative film (Fig. 5) shows a severe loss of lumbar lordosis, a so-called iatrogenic flat back, which is even more surprising because the description of the surgical procedure includes an extensive posterior decompression and instrumentation including complete facetectomies. It is probably explained by the far posterior positioning of the broad XLIF cages not permitting the required lordosis correction. The 6 weeks’ standing lateral film (Fig. 7) already shows a decompensated sagittal dysbalance, which is a predisposing factor for sacral instrumentation failure after long-segment lumbar arthrodeses. The sacral fracture that this patient suffered was almost certainly a consequence of both the unprotected sacral instrumentation and the iatrogenic sagittal dysbalance. When looking at the 6-month lateral standing film (Fig. 13) after extension of the instrumentation to the pelvis, I am convinced that with the sagittal dysbalance uncorrected and visibly progressing because of the superior decompensation, further surgery is unavoidable. I find it surprising that neither the article text nor the editorial perspective evenmentions the true clinical problem of this case.