Lower Lumbar Pain with Frequent 10/10 Leg Pain
The patient is a 55-year-old female with a 5-year history of severe low back pain. During the last 3 years her pain is worse. She describes her lower lumbar pain as constant and refractory to all treatments. Right leg pain is fairly frequent, radiates in the L5 distribution; the patient describes pain as 10 out of 10. She has no left leg pain.
The examination is unremarkable. Strength and reflexes are normal.
- Epidural steroid injections provide some relief
- Right L5 nerve root blocks provide significant but temporary relief
- Physical therapy was not successful
Movement exacerbates pain; rest helps to reduce pain. The patient's symptoms were refractory to all conservative treatments.
Imaging studies demonstrate no gross spondylolisthesis or instability on flexion or extension x-rays.
Lumbar MRI demonstrates multi-level spondylosis with collapse of the L3-L4 disc space and severe facet arthropathy at L4-L5 and L5-S1. No compression is seen on axial views.
There is no compression of the right L5 nerve root on imaging. (Fig. 1)
- Multi-level spondylosis
- Lumbar facet arthropathy
- L4-L5 bulging disc
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A spinal needle was localized at L4-L5 under fluoroscopy followed by a 5 cm midline incision. The paraspinal muscles were brought into relief. Using anteroposterior (AP) and lateral biplanar fluoroscopy, facet screws were placed at L4-L5 bilaterally using the following technique:
- A Jamshidi needle was placed over the facet and aimed inferiorly and laterally into the L5 pedicle. The K-wire was inserted through the Jamshidi into the pedicle, the Jamshidi needle was removed, a pilot hole was drilled over the K-wire, and a facet screw was placed over the K-wire bilaterally and compressed with a compressor. The K-wire was removed and AP and lateral fluoroscopy verified the construct.
- The interspinous ligament was resected at L4-L5, as well as some bone, which was morselized and mixed with 10 cc of demineralized bone matrix (DBM) putty. The posterior elements at L4 and L5 bilaterally were decorticated and the bone was laid down bilaterally between the L4 and L5 spinous processes and laminae.
- An Aspen™ interspinous fixation device (Aspen™ Spinous Process Fixation, LANX®, Broomfield, CO) measuring 8 mm in diameter was secured in place at L4-L5 and tightened with the final tightening screw torque screwdriver. Some more DBM putty was placed over the device in the interspinous space.
Intra-operative images (Figures 3A-3E)
Figure 3A. L4-L5 interbody space
The wound was closed in the usual fashion and the skin was closed with DERMABOND® (Ethicon, Inc., a Johnson & Johnson Company). Operative time was approximately 50 minutes. Blood loss was less than 50 cc and the patient was discharged home the day of surgery.
Surgeon's Treatment Rationale
Observing the patient's low back pain and severe leg pain was without obvious neural compression and coupled with imaging findings of severe facet arthropathy at L4-L5, I found the patient to be a candidate for a minimally invasive fusion.
I did not feel that either decompression alone or dynamic stabilization would suffice. Therefore, a facet fusion without decompression using Aspen™ Spinous Process Fixation was utilized at L4-L5.
I offered her a L4-L5 minimally invasive facet fusion utilizing the Aspen™ device combined with trans-facet screws bilaterally. The Aspen device is a spinous process fixation system with a central barrel. Biomechanical studies have shown the device significantly reduces range of motion of the spine in flexion and extension with additional restriction in lateral bending and axial rotation.
Utilizing Aspen in conjunction with facets screws offers stability comparable to bilateral pedicle screws. The result is a minimally invasive fusion procedure that reduces the surgical risk associated with pedicle screw placement.
The patient did well throughout and after surgery. She was released home the day of surgery.
Follow-up at 3 weeks: The patient pointed out that on post-operative day 2 or 3 she had complete resolution of her back and leg pain. On this post-operative visit she is taking no pain medication and is quite happy with the results. She has already resumed normal activities and is anxious to return to work.
Follow-up at 6 months: No back or leg pain. She described a tired feeling in her back at times, but this does not limit her activities. X-rays demonstrate no gross movement on flexion or extension. The device remains in good position at L4-L5 (Figs 4A-4B, 5A-5B).
Figure 4A. AP
Figure 4B. Lateral
Figure 5A. Flexion
Figure 5B. Extension
The patient telephoned to make her 1-year post-operative appointment. During this call, she stated she "continues to well without limitations and without back or leg pain." During the annual post-op appointment, appropriate CT imaging will be performed.
The descriptions of the results obtained from use of the Aspen Spinal Fixation System in this promotional piece are based on the physician's actual experience. The results achieved in any particular case using the Aspen device can vary and the results achieved in the case may not be typical. The use of the Aspen device entails certain risks, such as the possibility of implant bending or breakage, loosening, movement or migration of the device, or bone or spinous process fracture. In addition, the Aspen device should be used for only those indications described in the Package Insert for the Aspen device, entitled "Important Information on the Lanx Spinal Fixation System," a copy of which may be obtained by contacting Lanx Customer Service at 1.866.378.4195. Refer to the Package Insert for a more complete description of indications, contraindications, warnings and other information about the product.
The physician author of this case has not been compensated for his illustration by Lanx, Inc.
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Dr. Cowan presents a case that every spine surgeon has seen and treated. Today, as spine surgeons, we are exposed to a myriad of techniques, implants and treatment options for a case such as this. To paraphrase Kirkaldy-Willis, "management of back pain is too often based on empiricism, or worse, on the bias and training of the physician". Under these circumstances, isolating the painful culprit can be difficult and then prescribing the most appropriate and least invasive method of treatment can be confusing for the patient and surgeon.
Dr. Cowan elected to use a presumably newer and less invasive technique of spinal stabilization using an interspinous process stabilizing implant along with facet screws. I submit that experience over the past 50 years has allowed surgeons to focus their surgical maneuvers in order to minimize the collateral tissue damage, however, I would like to point out that neither interspinous process stabilization or facet screw fixation are new techniques.
Over 50 years ago orthopaedists were using split tibial autografts screwed into the spinous process to effect a fusion and likewise were using facet screws to lock the joints. In fact, one must question why do you even need an interspinous stabilization implant when there is abundant biomechanical and clinical scientific evidence that facet screw fixation on its own is adequate to facilitate a fusion?
Having stated the above, it appears that in the short term the patient is doing well and the long term outcome will have to be reconciled against the added cost of more implants.