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.
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:
- 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.
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.
Figure 1: Lateral radiograph demonstrating previous L5-S1 ALIF
Figure 2: AP radiograph demonstrating previous L5-S1 ALIF
Figure 3: Lateral flexion-extension
Figure 4: T1-weighted sagittal MRI demonstrating previous ALIF, a slightly degenerated disc at L4-L5, and a severely degenerated disc at L3-L4.
Figure 5: T2-weighted sagittal MRI demonstrating same issues as in Figure 4.
Severely degenerated disc at L3-L4
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
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.
Figure 6: 1 year post-operative AP radiograph showing L3-L4 TLIFand fixation.
Figure 7: 1 year post-operative lateral radiograph
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.