Severe Back and Left Lower Extremity Pain: Persists Five Years Post Laminectomy
Treatment of fractional curve in the setting of degenerative scoliosis
The patient is a 67-year-old female presenting with severe low back and worse left posterior thigh and lateral leg pain five years after multilevel laminectomy. Standing is her worst posture. Sitting affords her some, but not complete relief. Rigorous core strengthening and other nonoperative measures were not helpful.
Epidural injections provided variable improvement and she takes OxyContin®.
She has a previous medical history of lupus, breast cancer, and a bladder stimulator.
The patient is neurologically intact.
The patient's thoracolumbar anterior posterior and lumbar lateral x-rays are featured in Figs. 1A and 1B.
CT imaging was obtained. Figures 2A through 2C are coronal, sagittal and axial views. The arrow in Figures 2B and 2C show the L4 pars defect.
- Lumbar radiculopathy
- L4 pars defect in the setting of degenerative scoliosis
- Significant L3-L4 and L4-L5 asymmetric disc collapse
- Post-laminectomy syndrome
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I chose the Medtronic Direct Lateral Interbody Fusion (DLIF) and DePuy Viper™ percutaneous pedicle screw system to perform anterior-posterior fusion from L3 to L5. I felt I needed to satisfy three major treatment objectives: (1) treat her radiculopathy, (2) provide stability to her lumbar spine, and (3) do no harm.
I felt that her pain was arising mostly from the L3-L4 and L4-L5 segments, particularly noting her severe left-sided foraminal stenosis and lateral recess stenosis at L4-L5. A load-sharing device in the anterior column would not only provide optimal stability but, also maximize her opportunity of fusion success. I used BMP because of her steroid dependency. Lastly, because of her significant medical co-morbidities, I chose to treat her fractional curves rather than the entirety of her deformity.
Postoperative anterior posterior (Fig. 3A) and lateral (Fig. 3B) x-rays are featured.
Patient's quote, "It's a miracle!"
She is off all narcotics, takes over-the-counter NSAIDs for pain. There is a significant improvement in her walking tolerance up to one-hour. No hip flexor weakness.
Dr. Kwon has taken an approach to degenerative scoliosis that is gaining increased popularity. Traditionally, managing the entire curve with improved coronal and sagittal balance would mandate a more extensive procedure. Fusion from the lower thoracic spine to the sacrum would often be considered. Recently, less invasive procedures have demonstrated excellent outcomes with reduced estimated blood loss and shorter hospital stays.
At the North American Spine Society's 2009 annual meeting, recent reports clearly emphasized a positive correlation between improved sagittal balance and adult deformity outcomes. Direct lateral approaches allow surgeons access to the anterior column via less invasive means, excellent surface area for bony fusion, indirect decompression of neural elements, and segmental realignment of the spine.
This patient's pre-operative radiographs illustrate regional instability; L4 pars defect with reciprocal lateral listhesis at L3-L4 (collapse to the right) and L4-L5 (collapse to the left). An area of segmental instability can be a potential pain generator and, in the absence of functional improvement following an organized rehab program, would be the focus of surgical stabilization. The patient's case history did not mention any response to a core strengthening program as a pre-operative treatment option.
Postoperatively, the sagittal correction appears to restore balance, while the coronal correction is less than ideal and warrants close observation. The apex of the curve is at L2-L3 and shear stress on this level may predispose the patient to the development of junctional degeneration. Pre-operative bending films may have provided additional information if the pre-operative discussion included the possibility of extending the fusion to a more coronally stable level.
Minimally invasive spine surgery for adult deformity still should strive for sagittal and coronal balance. Short-term improvements may be of benefit to the patient, but may not solve the problem long-term. This being said, in my practice, short segment fusions have been successful. I would most likely have offered the patient a similar approach and continue to closely follow.
Dr. Kwon's patient responded well to the DLIF procedure. She has not experienced symptoms of thigh discomfort, paresthesia, or hip flexor weakness. Her underlying co-morbidities are another reason to consider a less invasive approach to this complex problem.
I thank Dr. Knight for his insightful comments. The patient had been managed by our Physical Medicine and Rehabilitation physicians for 2-years and had undergone many months of nonsurgical management, including a spine-specific core exercise program.
I agree with his concern with the cephalad extent of the fusion. Indeed, she does have notable asymmetry at L2-L3 susceptible to shear forces at the curve's apex. Fortunately, her curve had not changed significantly in the short-term and is being followed radiographically every 4-6 months. Additionally, she has remained clinically well and continues to make gains in pain, function and quality of life.