SpineUniverse Case Study Library

Severe Back and Left Lower Extremity Pain: Persists Five Years Post Laminectomy

Treatment of fractional curve in the setting of degenerative scoliosis

History

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.

Examination

The patient is neurologically intact.

Images

The patient's thoracolumbar anterior posterior and lumbar lateral x-rays are featured in Figs. 1A and 1B.

pretreatment thoracolumbar anterior posterior x-rayFigure 1A

pretreatment lumbar lateral x-rayFigure 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 coronal CT scan, L4 notedFigure 2A

lumbar axial Ct scanFigure 2B

lumbar axial CT scan, L4 pars defectFigure 2C

Diagnosis

  • Lumbar radiculopathy
  • L4 pars defect in the setting of degenerative scoliosis
  • Significant L3-L4 and L4-L5 asymmetric disc collapse
  • Post-laminectomy syndrome

Suggest Treatment

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Selected Treatment

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.

postoperative thoracolumbar anterior posterior x-rayFigure 3A

postoperative thoracolumbar lateral x-rayFigure 3B

Outcome

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.

Case Discussion

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.

Author's Response

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.

Community Case Discussion (2 comments)

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


It is clear that this lady has several reasons to explain her symptoms. She has severe scoliosis, which would place a lot of strain on the soft tissues and muscles around the lumbar spine and the hip. It appears that the R iliac crest stands higher than the L, which stands to reason if she has a scoliosis, the convex side to the R. We do not have a full pelvic xray to view this properly, and there is no mention of findings on a clinical examination.

She has severe facet joint pathology with several osteophytes which are liable to compress the lumbar nerve roots. She also has a severe lordosis which is extremely localised to the L4-5 and slightly less so to the L5-S1 vertebrae, rather than being spread out over 3-4 vertebrae; this will exacerbate her symptoms even more. There must be a functional reason explaining this finding.

Her pain is worse standing up. This could be for a number of reasons, which is difficult to surmise without discussing the physical examination:

1) facet joint pain gets worse standing up.

2) the pressure on the nerve roots is worse as a result of facet joint compression

3) She is straining the hip soft tissues and is bearing weight on what appears to be the higher or longer leg. This will strain the abductors of the R hip, which will cause pain when bearing weight., particularly, the posterior gluteus maximus.

4) She has reactive myofascial pain which is to be expected in a case such as this, where the scoliosis and hyperlordosis is so extreme and chronic. It is likely that she has active trigger points in the iliopsoas, gluteus medius and quadratus lumborum muscles. The iliopsoas is painfully symptomatic mostly on standing and can be responsible for exacerbating the localised lordosis. The gluteus medius trigger points can be painful whether sitting or bearing weight on one leg, and reacts to leg length discrepancy. The quadratus lumborum trigger points can cause excruciating chronic pain as cited by Travell and Simons; both of the latter muscles are often present in the case of scoliosis and cause considerable morbidity. I suspect that all of these are very active, and causing a lot of her pain.

I would get her checked out by someone who can evaluate her functionally in such a way, and treat her trigger points. This will certainly not treat her scoliosis or her facet joint pathology, however, it may well reduce the pressure on the facet joints, and reduce the pain emanating from her myofascial pain, which certainly is a contributing factor to her pain. In my experience, the pain may well be relieved for a period of 6 months after which time the treatment may have to be repeated.

Obviously, one has to make a very thorough functional clinical examination to rule out other functional pathology, and other soft tissue pathology, otherwise the relief of pain, if any, will be very short-lived. (Severe shortening of the quadratus lumborum may even cause a mild scoliosis which may disappear after treatment)

Nice case Brian but also very tough and furthermore increasingly more common. There was no mention of the often associated issue of osteoporosis which may also effect the "technical" success of the procedure.

There is a tendency to try and fix everything and we have some evidence to suggest that may be the way to go but much more outcome work is needed to compare the two appoaches. I could not help considering her co-morbidities which may shorten her overall life expectancy, which may seem judgemental, could be important for the long-term success of this operation. In other words if she were less "sick", she might need this to be more durable and so a more extensive and corrective procedure might be in order. The point being that we must all consider the case in front of us and avoid applying the same approach to everyone.

Your patient did well and it is hard to argue against success.

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