title: Metallosis Presenting as a Progressive Neurologic Deficit Four Years After a Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Case Report.
abstract: METHODS
  A case report.
  
  
  OBJECTIVE
  The aim of this study was to report a case of progressive pain and paraparesis secondary to metallosis four years after a pediatric posterior spinal fusion (PSF).
  
  
  BACKGROUND
  Metallosis as a late complication of pediatric spinal surgery is rarely reported. Myelographic computed tomography (CT) can be helpful in establishing the diagnosis. The use of serum chromium levels as a means of definitive diagnosis has been suggested, but has only been reported retrospectively.
  
  
  METHODS
  A 19-year-old male presented four years after PSF for adolescent idiopathic scoliosis with sudden onset of pain and neurologic deficits. Radiographs and CT scan suggested infection. Intraoperatively, no purulent material was noted, but black and yellowish corrosive debris was found around the right L1 pedicle screw, so it was removed and the cavity packed with tobramycin impregnated calcium sulfate beads. After surgery, neurologic deficits worsened. CT myelogram showed irregular opacification of the thecal sac at the level of the conus. A posterior laminectomy and decompression was performed with removal of all debris and spinal instrumentation. Metallosis within the spinal canal was noted and serum chromium levels were obtained.
  
  
  RESULTS
  The patient was discharged one week after admission with improvement of pain and gradual improvement in neurologic examination. Three years postdischarge, the patient is asymptomatic and examination shows bilateral clonus. Serum chromium levels declined from a high of 4.5 μg/L operatively to 0.8 at final follow-up (normal: 0.2-0.6 μg/L).
  
  
  CONCLUSIONS
  Although uncommon, metallosis should be considered in the differential diagnosis of any late presenting case of pain, infection-like symptoms, or neurologic deficits after pediatric PSF. CT myelography and serum chromium levels may help guide diagnosis; however, surgical exploration is needed for definitive diagnosis and treatment.
  
  
  METHODS
  4.
authors.affiliation: Cleveland Clinic Foundation, Cleveland, OH.
authors.forename: Seth H
authors.initials: SH
authors.lastname: Richman
authors.affiliation: Spectrum Orthopaedics, North Canton, OH.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Razzano
authors.affiliation: Akron Children's Hospital, Akron, OH.
authors.forename: Melanie A
authors.initials: MA
authors.lastname: Morscher
authors.affiliation: Akron Children's Hospital, Akron, OH.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Riley
mesh_terms: D000293:Adolescent; D002857:Chromium / Q000097:blood / Q000633:toxicity*; D019299:Decompression, Surgical; D020260:Heavy Metal Poisoning, Nervous System / Q000097:blood / Q000209:etiology*; D006801:Humans; D007796:Laminectomy; D008297:Male; D009192:Myelography; D010149:Postoperative Pain / Q000097:blood / Q000209:etiology*; D020335:Paraparesis / Q000097:blood / Q000209:etiology*; D011183:Postoperative Complications / Q000209:etiology*; D012600:Scoliosis / Q000601:surgery*; D013123:Spinal Fusion / Q000009:adverse effects*; D055815:Young Adult
chemical_list: D002857:Chromium