Lumbar Adjacent Segment Disease
A 72-year-old woman presents with low back pain and leg pain. Ten years ago, she underwent L4-S1 posterior decompression with instrumentation and fusion. Presently, her back pain is in the mid-lumbar region and is exacerbated with activity and improves when supine. The leg pain is predominantly in the right anterior thigh, occasionally in the left thigh. The patient reports cramping in both legs when ambulating. The patient rates her back pain as 9/10 on the visual analog scale, and her leg pain as 10/10 on the visual analog scale.
- Full strength in major muscle groups
- Sensation intact to light touch
- Reflexes symmetrically diminished
- Posterior lumbar incision well-healed
Ten years ago, the patient underwent a L4-S1 posterior decompression, pedicle screw fixation and posterolateral fusion from L4-S1 at another hospital.
Upon presentation to my office, she was on Norco 7.5 mg.
Under my care she has had physical therapy and epidural steroid injections without lasting pain relief.
Posteroanterior (Fig. 1) and lateral (Fig. 2) standing scoliosis x-rays show posterolateral fusion from L4-S1, a coronal deformity above the fusion construct, and adequate sagittal balance.
Figure 1 (below)
Figure 2 (below)
T2-weighted preoperative MRI. Sagittal (Fig. 3) and axial (Fig. 4) images reveal L3-L4 adjacent segment central canal stenosis.
Figure 3 (below)
- Adjacent segment disease
- Lumbar spinal stenosis
- Degenerative scoliosis
- Mechanical back pain
- Neurogenic claudication
- Lumbar radiculopathy
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L2-L3, L3-L4 direct lateral interbody fusion.
Intra-operative x-ray after patient positioning in the lateral decubitus position shows obvious coronal deformity at the adjacent segments (Fig. 5).
Figure 5 (below)
Postoperative imaging shows L2-L3, L3-L4 direct lateral interbody fusions (DLIF) with lateral plating and adequate correction of the coronal deformity (Fig. 6).
Figure 6 (Below)
Pre-operatively, the option of posterior neural decompression after lateral interbody fusion in a staged manner was discussed with the patient, but she awoke from the DLIF with improved back pain and leg pain.
She was ambulating on postoperative day 1 and discharged on postoperative day 2.
At 3-month follow-up, she continues to experience relief of back and leg pain. Radiography shows early graft incorporation and stable spinal alignment.
This 72-year-old woman status post previous L4-S1 posterior fusion presented with mechanical back pain and neurogenic claudication. Her x-rays demonstrate coronal and sagittal balance, and MRI reveals adjacent segment disease at L3-L4 with severe stenosis at that level. Other studies that may be useful in this patient's work-up include a CT scan to assess her fusion, as well as flexion/extension lumbar films to assess for dynamic instability.
In my mind, the surgical options for this patient include decompression in conjunction with extending her fusion up one level posteriorly or laterally. Given her degree of stenosis due to both disc herniation and ligamentous hypertrophy, I would have performed a L3-L4 laminectomy and transforaminal lumbar interbody fusion, for a final construct spanning from L3-S1. I would have likely left L2-L3 alone given the reasonable appearance of that level on MRI and her rather mild coronal deformity.
This patient did well and appears to have gotten enough relief from an indirect decompression. Dr. Oppenlander is to be commended on an excellent surgical result.