SpineUniverse Case Study Library

Lumbar Disc Degeneration: 2 Previous Spine Surgeries and Constant Low Back Pain


A 57-year-old, slightly overweight male presented with a 2 year history of progressive low back pain. It was predominantly left sided-pain, and the pain was present at all times. However, it worsens with increased activity. The patient has no leg pain, but he does have some gait difficulty due to low back pain.

Prior Treatment

In 1992, this patient had a lumbar decompression, and he did well following that surgery. In 1999, he had an L5-S1 ALIF. He did well following that surgery, as well.

To address his current low back pain, the patient has tried:

  • NSAIDs
  • Muscle relaxants
  • Physical therapy
  • Analgesics (Vicodin)
  • Epidural blocks/facet blocks

These conservative measures have not brought relief.


In the physical exam, it was noted that the patient had reduced lumbar ROM in all directions. His motor response was 5/5, and sensory was intact.

The DTRs were symmetric, and the SLRs were negative.

There was palpable tenderness in his lower lumbar spine.

A discography was performed, and it was positive with concordant pain at L3-L4. It was normal at L4-L5, which was a slightly degenerated disc.

Psychosocial Issues
It's important to consider the psychosocial issues:

  • The patient continues to work.
  • There are no secondary gain issues.
  • He does not smoke.
  • He has moderate analgesic usage.
  • Seems like a motivated patient.

Pre-treatment Images

fig1 Kalfas Lumbar Disc Degeneration Lat Pre-op X-ray

Figure 1: Lateral radiograph demonstrating previous L5-S1 ALIF


fig2 Kalfas Lumbar Disc Degeneration AP Pre-op X-rayFigure 2: AP radiograph demonstrating previous L5-S1 ALIF


fig3 Kalfas Lumbar Disc Degeneration Lat Pre-op Flex-Ext X-raysFigure 3: Lateral flexion-extension


fig4 Kalfas Lumbar Disc Degeneration Sag Pre-op T1 MRIFigure 4: T1-weighted sagittal MRI demonstrating previous ALIF, a slightly degenerated disc at L4-L5, and a severely degenerated disc at L3-L4.


fig5 Kalfas Lumbar Disc Degeneration Sag Pre-op T2 MRIFigure 5: T2-weighted sagittal MRI demonstrating same issues as in Figure 4.


Severely degenerated disc at L3-L4

Suggest Treatment

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Selected Treatment

A TLIF with pedicle fixation was performed at L3-L4. Because the discogram showed that the L4-L5 disc was normal, it was not necessary to fuse that level.


The patient is now 2 years post-op, and he continues to do well.

fig6 Kalfas Lumbar Disc Degeneration AP Post-op X-rayFigure 6: 1 year post-operative AP radiograph showing L3-L4 TLIFand fixation.


fig7 Kalfas Lumbar Disc Degeneration Lat Post-op X-rayFigure 7: 1 year post-operative lateral radiograph

Case Discussion

I think the treating surgeon did a great job. The x-rays looks good. I used to do quite a few TLIFs but I have switched mostly to the lateral approach (XLIF/DLIF). My reasoning is that I do not have to worry as much about the exiting nerve, and I can get a much larger discectomy and spacer in the disc space—frequently 50 to 55mm. I usually will back them up with a lateral plate or posterior screw and rods.

Community Case Discussion (6 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.

i would have done an investigation of the hip & SI joints with a CT & SI jt blocks to totally determine the cause. also if you have done a L3-L4 TLIF, then why have you done a L4 laminectomy?

Look forward to seeing the L4-5 fusion next year.

The L4L5 disc space was normal. A simpler approach would be an instrumented L3L4 posterior-lateral fusion fusing the transverse processes and the facets. This standard surgery was not an option.

MRI shows degenerated disc at L3-4 and Modic changes GII at same level, so fusion decesion is suitable. However adjacent segment complication is predicted I will choose the same procedures.

I agree that the patient needed a P/TLIF at L3-4. Certainly the L4-5 disc is not normal, just not yet symptomatic. But I agree it radidly will be symptomatic and will require fusion within 3 years. Thus in this situation I usually P/TLIF L3-4 and do posterolateral with inst at L4-5. This adds minimally to the recovery of this procedure, adds about 15 minutes to the case, and prevents the inevitable second surgery. Interestingly in this situation with an intermediate asymptomatic disc if you get a solid posterolateral fusion the disc is protected and does not usu degenerate on MRI.

I think this is where XLIF (or associated procedures) is ideal, because although 4-5 is at risk, we don't know what the future holds, and its the best looking disc in her spine. All posterior surgery before and now, and I would say you're crazy to think it will last, but stand alone ALIF's can last a really long time with no ASD (no paraspinal stripping, no pedicle screws banging up the next facet), and an XLIF at 3-4 or above works really nice. I have almost the exact same patient who is getting a 2-3 XLIF above a 4-5 old ALIF, and a little hard to look at the xrays but I really think its the right thing to do. Would not agree with a TLIF above another TLIF. No one really knows though.


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