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Lumbar Degenerative Disc Disease: History of Low Back Pain

Patient History

The patient is a 62-year-old male with a three year history of low back pain that prevents him from normal activities. Although his leg pain is minimal, it is increased with activity and decreases when lying down.

Examination

The examination is normal.

Prior Treatment

The patient tried physical therapy, nonsteroidal anti-inflammatory drugs, epidural steroid injections, and chiropractic.

Images

posterior anterior lumbar x-ray
Figure 1A. Posterior anterior

 

lumbar flexion x-ray
Figure 1B. Flexion

lumbar extension x-ray
Figure 1C. Extension

sagittal lumbar MRI, stenosis, endplate Modic changes at L4-L5
Figure 2A. Sagittal MRI shows lumbar stenosis and endplate Modic changes at L4-L5

axial lumbar MRI, stenosis caused by a bulging disc, ligament hypertrophy
Figure 2B. Axial MRI shows that stenosis is from both a bulging disc and ligament hypertrophy

Diagnosis

  • Lumbar stenosis, L4-L5
  • Instability, L4-L5

Suggest Treatment

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Selected Treatment

Because of the Modic changes in the endplates at L4-L5, and the major component of back pain in his presentation, it was felt that instability was present at that level. Therefore, decompression alone had a low probability of achieving a successful result. The patient underwent a unilateral L4-L5 MIS TLIF with posterior instrumentation.

 

postoperative anterior posterior lumbar x-ray, L4-L5 TLIF
Figure 3A. Postoperative anterior posterior x-ray

postoperative lateral lumbar x-ray, L4-L5 TLIF
Figure 3B. Postoperative lateral x-ray

Outcome

At one year post op, the patient had returned to all preoperative activities, including golf, with minimal pain.

Case Discussion

This is a 62-year-old male with predominant back pain with activity-related leg pain that has failed conservative therapy.

Imaging studies are consistent with Grade 1 dynamic listhesis, endplate Modic changes, with stenosis and fluid in the facet joints. All are suggestive of pathology at the L4-L5 level.

While the argument can be entertained as to, "how do we rule out L5-S1 as also being a pain generator," the imaging findings would suggest that the pathology is predominantly at L4-L5 - and, I personally agree that this is the level to treat and ignore L5-S1.

I also agree that given the patient has predominant back pain with instability, that stabilization is indicated.

Stabilization may be with or without a fusion. The only other possibility I would introduce would be consideration for a non-fusion dynamic stabilization. Given that we do not have good long-term outcome data on non-fusion stabilization, the gold standard of stabilization with fusion seems appropriate for this patient.

An MIS TLIF provides for stabilization with fusion and without the collateral damage associated with extensive muscle stripping. In the setting of predominant back pain, this may be an important consideration.

John J. Carbone, MD
John J. Carbone, MD

Orthopaedic Spine Surgeon
Harborview Reconstructive Spine and Orthopaedic Specialists
Baltimore, MD

This patient demonstrates a classic picture of mechanical back pain. Pain worsens with activity or load and resolves when supine. A helpful, though controversial study, is a lumbar discogram, which may help delineate which disc and the extent or number of painful discs present.

The patient has failed nonoperative care and is no longer able to continue normal activities. While the MRI may demonstrate foraminal stenosis, the symptoms are not consistent with radiculopathy or leg pain due to neural compression, so decompressive surgery alone is not indicated.

Of the selected treatments, only spinal fusion surgery and disc replacement surgery directly address back pain and indirectly foraminal stenosis. The MRI clearly demonstrates facet arthrosis. Disc replacement alone would not address the posterior elements and is therefore contraindicated.

The type of spinal fusion selected is specific to the surgeon's preference and experience. Similar results have been demonstrated by open decompression / fusion, mini-open decompression / fusion, or posterior stand alone (no TLIF or PLIF with anterior support) decompression fusion.

The concept of spinal fusion for the successful treatment of axial back pain is the take home message in this case.

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