Delayed hypersensitivity reaction caused by metal-on-metal total disc replacement

Abstract

<jats:p>The authors report the case of a 53-year-old woman who underwent placement of a metal-on-metal total disc replacement (TDR) device for the treatment of discogenic back pain. The initial postoperative course was normal, but 2 months after surgery she started to complain of a recurrence of pain and she progressively developed cauda equina syndrome. Radiological and biological findings showed an inflammatory polyneuropathy associated with an epidural mass. A diagnosis of cell-mediated hypersensitivity reaction (Type IV) was made after patch testing showed positive reactions for 1% cobalt chloride and chromium. A decision was made to remove the TDR device and to perform a circumferential fusion. This report is intended to inform the reader that systemic metal release and hypersensitivity reaction are possible complications of metal-on-metal TDR.</jats:p>

Metal hypersensitivity in patient with posterior lumbar spine fusion: a case report and its literature review

“…Although preoperative history-taking alone appears to be insufficient for identifying patients with metal sensitivity[ 7 ], it is still strongly recommended to be taken thoroughly, because this could provide a strong clue towards the delayed postoperative pain in time, and therewith, a timely customized examination and treatment could be conducted to benefit the patient tremendously. In this case, the patient sustained low back pain for another 5 months because of the difficulty in diagnosis, but the related signs and symptoms resolved shortly after removal of the metal instruments like other cases reported[ 25 – 27 ].…”

Maverick total disc replacement in a real-world patient population: a prospective, multicentre, observational study

“…The Maverick RCT also reported one case of metallurgic allergy at 7 months [9]. This rare problem has been previously noted and is due to the creation of ionic species at the metallic articulating surfaces precipitating a cell-mediated hypersensitivity reaction (type IV) [15,16].…”

Delayed Hypersensitivity Reaction: An Increasingly Recognized Complication of Metal-on-Metal Total Disc Replacement

“…The proper placement of the prosthesis and the choice of appropriate materials should be carefully considered when a total disc replacement is suited. Regarding the spine, there are only few cases reported to date [ 4 , 9 , 10 ]. However, the delayed diagnosis due to the lack of knowledge of this disease and the proximity of visceral and neurological structures may be responsible for dreaded and mainly irreversible sequelae [ 4 , 10 ].…”

“…Most of time, MRI and CT scan provide only limited help because of the importance of metal artefacts. Other diagnostic tools must be considered such as scintigraphy, which can show an intense fixation or computed tomography myelogram that can reveal a foraminal and epidural mass [ 4 , 11 ]. When performed, the cerebrospinal fluid analysis can demonstrate high protein content and lymphocytic pleocytosis [ 4 ].…”

“…Repetitive movements and progressive wear of surfaces cause the release of metal ions, leading to delayed hypersensitivity reaction [ 3 ]. Such reaction can induce various symptoms such axial pain, radiculopathy, spinal cord compression, or pseudotumor mass [ 4 ]. The diagnosis is even more difficult to establish due to the radiological artefacts caused by the prosthesis.…”