Debilitating Back Pain with Neurogenic Claudication
The patient is a 76-year-old female who presents with debilitating back pain, sagittal imbalance, and neurogenic claudication. Symptoms have progressively worsened the past 2 years.
Neurologically, the patient is intact. She is takes no medication, except narcotics for pain.
She tried, without success, physical therapy, epidural steroid injections, facet blocks, acupuncture, and yoga.
The AP radiograph (Fig. 1A) shows degenerative scoliosis in the coronal plane. Sagittal imbalance is demonstrated in the lateral radiograph (Fig. 1B).
CT images shown in Figures 2A and 2B.
Lumbar degenerative disc disease with scoliosis and spinal stenosis.
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During the first stage, the patient underwent a direct lateral transpsoas lumbar interbody fusion at L2-L3, L3-L4, and L4-L5. This was followed with the TranS1® AxiaLIF™ system to stabilize the L5-S1 segment. The AP and lateral radiographs show the implanted device in the lumbar spine. (Figs. 3A-3D)
The patient was ambulated in between stages and had no leg pain on walking after the first stage.
In the second stage, percutaneous T10 to S1 instrumentation was carried out using Medtronic's CD HORIZON® LONGITUDE™ System.
Intraoperative photos show the CD HORIZON® LONGITUDE™ System (Fig. 4A) with percutaneous passage of a rod (Fig. 4B).
Intraoperative photos after the second stage are shown in Figures 5A through 5F.
View implantation of the TranS1® AxiaLIF™ device.
Neel Anand, MD serves as a consultant to TranS1®, Inc.
At 2-weeks postop, the patient's incisions (Fig. 6A) are well healed and she is standing upright (Fig. 6B-6C). At 1-year postop, she is doing well and has resumed an active life. (Fig. 7A, 7B)
This is an archetypical patient spine surgeons see regularly in practice. She is an elderly woman with degenerative lumbar scoliosis. Her main complaint is lower back pain and she is functionally limited by pain. Nonoperative treatment is ineffective.
Traditionally, options have been limited for surgical intervention. Comorbidities often exclude the possibility of a large open surgery. Poor bone quality limits deformity correction and screw purchase. Fusion results are poor. In my experience, some patients undergo lumbar laminectomies. The laminectomies exacerbate the patient's deformity and ultimately the patient worsens clinically.
In the above case, the author uses an amalgam of several new surgical techniques to address the elderly female patient with degenerative lumbar scoliosis. The techniques include extreme lateral interbody fusion (XLIF), trans-sacral L5-S1 fusion (AxiaLIF), and percutaneous pedicle screws.
The author reports the patient has neurogenic claudication, although no MRI or CT myelogram showing stenosis is presented. The surgeries described involve no direct decompression for lumbar stenosis. I believe establishing whether there is real central stenosis and neurogenic claudication is essential for surgical planning. A laminectomy may be necessary for severe central stenosis with neurogenic claudication. Often, these patients do not have neurogenic claudication but, mostly lower back pain and an associated radiculopathy due to foraminal stenosis.
The initial pre-operative x-rays show a significant coronal scoliosis and a large positive sagittal balance. The preoperative CT scan reconstructions show a significantly lesser deformity indicating there is a fair amount of flexibility and some deformity correction could be achieved with positioning. Flexion / extension x-rays and side bending films are worthwhile to evaluate.
After the first stage, involving XLIFs at L2-L3, L3-L4, L4-L5, and an AxiaLIF at L5-S1, x-rays show an improvement in overall sagittal balance. The coronal scoliosis is also improved. The patient reportedly has an improvement in leg pain, presumably from foraminal distraction, since no decompressive procedure was done. Percutaneous pedicle screws are placed in a staged procedure from T10 down to S1. Interestingly, while screws are placed from T10 to S1, a fusion is only done at L2 to S1. One would expect, without a fusion, instrumentation across T10-T11, T11-T12, T12-L1, and L1-L2 would likely fail. The levels span the relatively mobile thoracolumbar junction.
In summary, the elderly patient with degenerative lumbar scoliosis is a difficult problem. For many such patients, the ability to ambulate is severely limited and quality of life is diminished. Nonoperative therapies are often ineffective. Traditional surgical techniques have not yielded good results in this patient population. I applaud the author for tackling this difficult issue creatively. My own experience is long construct fusion rates are poor in older patients and limited surgeries not addressing the deformity often are ineffective. If patients have predominately radicular symptoms, a foraminotomy may address the radicular symptoms without further destabilizing the spine.
Correlation of physical examination and specific nerve root radiculopathy with MRI findings is essential. I have also had some success using the XLIF procedure to improve overall sagittal alignment and increase foraminal height. I would be cautious about setting the endpoint, as making the x-rays look good in this patient population. Definitely, further research and studies would be welcome to establish a better treatment paradigm. As the population ages, we will increasingly be faced with this dilemma.
Dr. Deutsch, very appropriately, has commented on the stenosis and neurogenic claudication issue. As suggested by him, the patient had foraminal stenosis at L3-L4 and L4-L5 with no significant central stenosis.
After the first stage, the patient was ambulated and had complete relief of all radicular symptoms. Hence, no decompressive procedure was carried out in the second stage.
A facet fusion augmented with rh-BMP-2 was carried out at all the levels that did not have the interbody fusion during the second stage. The proximal levels were thus augmented and final x-rays have shown solid fusion at all levels at 1-year.
We certainly agree that these are very challenging cases. We have a consecutive series of such patients treated in this manner that we are closely following and reporting on at various scientific meetings.