Abstract
BACKGROUND: Spinal reconstruction of an L5 osteoporotic vertebral fracture (OVF) is a demanding surgery because of the condition's rarity, poor bone quality, and anatomical reasons. To date, there has been little debate regarding the surgical strategy for L5 OVF and effective osteoporosis treatment. The authors report L5 osteotomy and adjuvant romosozumab (ROMO) therapy for L5 OVF-induced spinal deformity. OBSERVATIONS: A 73-year-old woman underwent lumbopelvic instrumentation and fusion from L3 to the pelvis, L5 osteotomy combined with unilateral posterior vertebral column resection (VCR), followed by expandable cage replacement and bone biopsy simultaneously. Histomorphometric analysis of the bone biopsy showed accelerated bone formation in the endocortical region of the spinous process. After surgery, her low back pain and leg pain improved with satisfactory global alignment. At the 2-year follow-up, lumbopelvic reconstruction achieved fusion, with minimal reciprocal change and no mechanical failure. The patient's Oswestry Disability Index improved from 64% to 24%. L5 osteotomy combined with unilateral VCR and expandable cage replacement was a safe and effective technique in this case. LESSONS: This technique can provide both greater restoration of lower lumbar lordosis and pelvic tilt with fusion. Moreover, adjuvant ROMO therapy has the potential to prevent osteoporosis-related complications. https://thejns.org/doi/10.3171/CASE24633.