Retired Truck Driver with Progressive Axial Low Back Pain
Presents with Radiculopathy, and Cauda Equina Syndrome
The patient is a 66-year-old male retired security truck driver. He underwent an L3-S1 in situ fusion for leg pain and spondylolisthesis 30 years prior to presenting in our office.
The patient’s history included 10 years of progressive axial low back pain. Radiculopathy developed 18 months prior to presentation, and cauda equina syndrome developed 6 months prior to presentation.
The patient presented to our office with a primary complaint of pain that worsens with activity and at the end of the day.
The patient’s physical exam showed that he bends his knees forward when standing, leading to ventral / sagittal imbalance.
Patient had right thigh pain above the knee. Radicular symptoms were greater than claudatory.
Neurologic work up indicated a conus compression syndrome, giving him buttock and scrotal numbness (relieved by sitting).
Diagnostic arthrogram on his right hip was performed, but did not provide concordant pain relief.
He has an ODI of 45.
The patient had undergone extensive non-operative treatments, including physical therapy, rehabilitation, and analgesic management.
Figure 1 Pre-op sagittal MRI
Figure 2 Pre-op sagittal MRI
Figure 3 Pre-op axial MRI
Figure 4 Pre-op AP x-ray
Figure 5 Pre-op AP x-ray
Figure 6 Pre-op lateral x-ray
Figure 7: Pre-op AP x-ray showing signs of hip arthritis, but this is not the cause of dominant pain
Figures 8A and 8B: Pre-op CTs; note solid fusion up to L4
Figure 9 Pre-op clinical photo of patient
The patient was diagnosed with flat back syndrome, L3 radiculopathy, and cauda equina syndrome (positional).
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We performed direct lateral discectomies from L3-T8, with lateral interbody fusion. And returned to the OR 4 days later to perform posterior percutaneous instrumentation and facetectomies, with resection of pseudarthrosis at L3-L4. In our practice, we stage operative procedures that have potential to exceed 8 hours or those that include a prone component to reduce peri-operative risks of coagulopathy, excessive blood loss, PION etc.
We instrumented from T8-sacrum. Screw orientation in proximal junctional segments is lateral to medial and is in a cepholocaudad orientation.
Cage placement at L3-L4 is relatively posterior, hence hindering full restoration of lordosis.
Figures 10A and 10B: Sagittal CTs; on the left is pre-stage 1 (anterior release). Compare this to the image on the right, which was taken following the anterior release.
Figures 11A and 11B: Post-stage 2 AP and lateral x-rays showing instrumentation and improved alignment.
Figures 12A and 12B: Comparison of pre-operative and post-operative clinical photos
Lordosis was restored from -20° to 50°. The patient’s leg and back pain dramatically improved (VAS 6 and 8 to 1 and 2, respectively). His 12-month ODI was 8, and he is active in ADLs and takes occasional Tylenol for knee pain.
A case of a 66-year-old man with significant degenerative changes above a prior L3 to S1 in situ fusion is presented. Both his clinical presentation and radiographic evaluation are consistent with a picture of sagittal imbalance. The degenerative changes at the thoracolumbar junction have resulted in kyphosis across these segments with a mild scoliosis. The long-cassette radiographs demonstrate sagittal imbalance. Unfortunately, the lateral radiograph does not show the hip joints that would make the calculations for optimal correction easier.
An ideal surgical outcome would result in the sagittal vertical axis being within 5 cm of the posterior-superior S1 endplate, the pelvic tilt less than 25 degrees, and the lumbar lordosis proportional to the pelvic incidence. Considering the poor results of non-operative management for sagittal malalignment, surgical intervention is needed for the substantially symptomatic patient.
There are several surgical approaches that could be theoretically performed. Depending on the amount of correction needed, release procedures—such as Chevron osteotomies, pedicle subtraction osteotomy, or some form of circumferential fusion—may be utilized. In this case, lateral discectomies were performed from T8 to L3 in order to correct the deformity and more predictably achieve fusion. A second-stage posterior T8 to sacrum instrumentation and fusion was performed. The T8 level is frequently avoided in treatment of adult deformity due to this level frequently being near the apex of the thoracic kyphosis and concerns about precipitating proximal junctional kyphosis.The post-operative radiographs show substantial improvement in the sagittal vertical axis. Whether ideal alignment was actually achieved is difficult to determine without the hip joints visualized. Although the clinical photographs show substantial improvement, there appears to be a mild residual postural abnormality present. This case clearly demonstrates the powerful corrective capabilities of the direct lateral transpsoas procedure. An excellent radiographic result was achieved using this technique.