Low Back and Leg Pain Refractory to Conservative Treatment
Geriatric patient, past laminectomy
The patient is a 76-year-old male with a longstanding history of low back pain and bilateral lower extremity symptoms secondary to spondylolisthesis. He had a laminectomy in the past (year unknown) and presents with new MRI findings indicating bilateral L4-L5 and L5-S1 foraminal stenosis. Left leg pain is worse than the back pain.
He denies any bowel or bladder dysfunction. He does not use tobacco.
Past medical history is positive for cancer, depression, abdominal aortic aneurysm, rotator cuff repair, and laminectomy.
Medications include hydrocholorothiazide, lisinopril, clonazepam, Lipitor, Colace, and baby aspirin.
- Stooped stance
- Positive straight leg raise on the left; negative on the right
- Mild tenderness at the sciatic notches on the left versus the right
- Flexion to 50-degrees, extension to 15-degrees
- Pain with hyperextension and facet loading
- No trochanteric tenderness
- Normal motor and sensory reflex from L2-S1
- Neurovascularly entirely intact
- 2+ pulses
- Non-steroidal anti-inflammatory drugs
- Prescription pain medication
- Transforaminal epidural steroid injections
- Lumbar facet block at L4-L5 and L5-S1 bilaterally
- Transforaminal nerve root block at left sides of L4-L5 and L5-S1
- Radiofrequency ablation of the medial nerves at L4-L5 and L5-S1
- Organized physical therapy program
The patient's symptoms were refractory to all conservative treatments.
Figure 1A. Anteroposterior
Figure 1B. Lateral
Figure 1C. Flexion
Figure 1D. Extension
Sagittal MR imaging (Figures 2A-2C)
Axial MR image of L4-L5 (Figure 3)
- L4-L5 degenerative spondylolisthesis (Grade 1), bilateral foraminal and lateral recess stenosis
- Right L5-S1 lateral recess stenosis
- Right-sided L4-L5 disc herniation
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
- Revision L4 and L5 bilateral foraminotomies, medial facetectomies and right-sided microdiscectomy
- Right-sided L5-S1 lateral recess decompression, partial medial facetectomy and foraminotomy
- L4-L5 posterior spinal fusion and instrumentation using spinous process plating (Aspen™ Spinous Process Fixation System, LANX®, Broomfield, CO) and bone morphogenetic protein (BMP) (Infuse®, Medtronic, Inc., Memphis, TN)
- L4-L5 posterior interbody fusion using BMP (Infuse®)
The patient failed conservative therapy so additional physical therapy and injections are unwarranted. Reports of failure with the X-STOP (X-STOP® Spacer, Medtronic Spine LLC, Memphis, TN) device in patients with spondylolisthesis are growing. In this patient, additional decompression alone may result in further instability. The aim was to minimize the surgical impact and provide maximal surgical effectiveness.
A microdiscectomy, decompression and posterior fusion with instrumentation was selected for this patient. With the knowledge that instrumentation increases fusion rates, the choice was fixation with the Aspen device. The Aspen device is unique, in that it provides stabilization to promote fusion with the addition of a load-sharing barrel shown to have a positive effect on foraminal height in cadaveric testing, while eliminating the risk associated with pedicle screw placement. The minimal tissue disruption and approach required to place the Aspen posterior fixation device is preferred over pedicle screw fixation in this patient.
- Using landmarks of the iliac crest, posterior superior iliac spine and prior scar line, a 5-cm incision was made in the midline. Dissection was carried bilaterally to the laminae of L4 through S1. Cross-table fluoroscopic imaging confirmed dissection position.
- The operating microscope was brought into the operative field. Laminotomies were performed by removing the previous scar off the intervals and delineating the interspace. Scarred ligamentum flavum and dura mater was removed off the edge of the previous laminotomy defect after performing extension of the bilateral laminotomy at L4-L5 and at the right side of L5-S1. This was done with the aid of an operating microscope.
- In each instance, traversing ligamentum flavum was removed and the traversing nerve root identified. There was moderate scarring of the ligamentum flavum to the dura mater on the right side at L5-S1 as well as L4-L5.
- There was significant lateral recess compression bilaterally at L4-L5 and significant facet overgrowth too. Once the lateral recess was decompressed and the traversing nerve roots were felt to be completely decompressed without any compression at L4-L5 and L5-S1, the lateral recess decompression was felt to be complete.
- The right side of the scarred dura mater was adhered to a disc herniation. The disc herniation was removed piecemeal through a cruciate annulotomy. The disc space was entered and cleared of disc material to the bleeding surface of bone. The space was packed with a BMP sponge and sealed with DuraSeal™ (Covidien, Waltham, MA) to avoid nerve root irritation from the BMP. This completed the decompressive and interbody fusion portions of the procedure.
- Posterior fusion was performed in 2 parts; decortication of the facet joints and placement of autograft plus half a BMP sponge into each facet joint. The L4-L5 interval was slightly distracted to allow for additional decompression of the foramen. Lordosis was maintained with the LANX® Aspen™ plate. The device was filled with BMP and, after decorticating the spinous processes, was placed in the interval. It measured 14-mm in diameter. Purchase of the plate was found to be excellent. The last BMP sponge was packed behind the cage between the spinous processes.
- The wound was closed in layers and dressed in sterile style.
Overall, the procedure was well-tolerated by the patient. He was transferred to the recovery room in stable condition.
Figure 4A. Anteroposterior
Figure 4B. Lateral
The patient did well and was discharged home on post-operative day one. He was provided a prescription and instructions for taking a pain medication (Percocet). Activity restrictions were provided and included no repetitive lifting, bending, twisting, pushing, or pulling.
2 weeks post-op: The patient is doing well. His incision is well-healed; no sign of infection. He is taking 2 Percocet a day in the morning; otherwise, his pain is improving. He has some pain in his buttocks but leg pain has significantly improved. Back pain is minimal. No fevers, chills or night sweats. At this time, he is using a bone stimulator. His gait is nonantalgic and he uses a walker outside his house. Motor and sensory exam (L3 through S1) is normal. Palpable pedal pulses. Calves are benign. Neurovascularly, he is intact.
10 weeks post-op: Back and leg pain continues to subside. He is compliant with restrictions (no bending, lifting, twisting, carry heavy objects). He has excellent lumbar range of motion. Flexion does elicit some discomfort. He can heel and toe walk without difficulty. L2-S1 nerve root distributions are intact on motor and sensory testing. An organized program of physical therapy is discussed and scheduled to begin near 3 months post-op.
Radiographs demonstrate the Aspen device to be in good alignment. There appears to be some fusion occurring in the facets. These appear slightly increased radiodense compared to the levels above.
5 months post-op: The patient continues to do well. He is participating in physical therapy and sees improvement. Use of the bone stimulator is reduced to about 4 hours each day. He states he has "virtually no pain unless he pushes himself and then gets an occurrence of some lower back pain; however, it is short-lived if he sits down."
There is some mild tenderness to palpation over his paraspinal muscles. Flexion to 90-degrees and extension of 10-degrees is not difficult.
Radiographs (Figures 5A-5D) show excellent placement of the Aspen device. No osteolysis or loosening noted. There was evidence of some fusion at the location of the device.
Figure 5A. Anteroposterior
Figure 5B. Lateral
Figure 5C. Flexion
Figure 5D. Extension
- Sensation is bilaterally intact from L2 to S1
- 5/5 strength at the hip flexors, quadriceps, anterior tibialis, gastrocnemius soleus, peroneals, and extensor hallucis longus muscles
- Patellar and Achilles reflexes are bilaterally brisk and equal
- Bilaterally, negative clonus
- Calves are supple and not tender to palpation
- Pedal pulses are 2+/4
6 months post-op: The patient reports no low back or leg pain. He has completed physical therapy and is working out at the gym to build muscle tone and endurance. He feels a little bit of left lateral hip pain/buttock pain when walking on the treadmill. He takes no pain medication. A left trochanteric bursal injection is recommended for the lateral hip pain.
8 months post-op: Overall, the patient is doing extremely well. All lower extremity symptoms have resolved; no pain, tingling or weakness. The left-sided greater trochanteric bursitis is totally resolved following the cortisone injection. He continues to work out at the gym.
The descriptions of the results obtained from use of the Aspen Spinal Fixation System in this promotional piece are based on the physician's actual experience. The results achieved in any particular case using the Aspen device can vary and the results achieved in the case may not be typical. The use of the Aspen device entails certain risks, such as the possibility of implant bending or breakage, loosening, movement or migration of the device, or bone or spinous process fracture. In addition, the Aspen device should be used for only those indications described in the Package Insert for the Aspen device, entitled "Important Information on the Lanx Spinal Fixation System," a copy of which may be obtained by contacting Lanx Customer Service at 1.866.378.4195. Refer to the Package Insert for a more complete description of indications, contraindications, warnings and other information about the product.
The physician author of this case has been compensated for his illustration by Lanx, Inc. and has stock ownership in Lanx, Inc.
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This is an excellent case and it represents the majority of cases spine surgeons treat. Like most cases, this patient presents after exhausting non-operative treatments. I agree this patient requires surgical intervention. In such patients, I view age, weight and activity level as important factors in conjunction with comorbidities. Much can be learned by asking the patient how their problem affects their quality of life and what they hope to achieve with treatment.
The patient is 76-years old with some significant medical history. His x-rays demonstrate severe spondylitic collapse of L5-S1 with facet hypertrophy. This probably started or contributed to the cascade leading to development of a Grade 1 spondylolisthesis at L4-L5 which is unchanged on flexion or extension. MR images or MRIs in conjunction with plain films would provide a more defined picture of this patient's problem. While the L3-L4 segment is fairly normal, the level above requires a differential diagnosis. Since the L3-L4 level appears to be normal, I would not include L4-L5.
In my hands, I'd offer a definitive procedure to address his low back pain and neurogenic claudication. However, X-STOP® is a poor choice for this patient with two-level disease and spondylolisthesis. Early symptomatic relief could be short-lived and there is a high failure rate in patients with spondylolisthesis. Decompression alone - in any form - such as laminectomy or foraminotomy, are poor choices that would not address this patient's problems and likely lead to additional surgery.
My surgical choice is decompression and fusion with foraminotomies. It is important to address the patient's hypertrophy and, to obtain a good decompression, it is necessary to perform a complete laminectomy/medial facetectomy. Inclusion of fusion allows more aggressive decompression. Foraminotomies may not completely address his spinal stenosis.
If the patient is active and has good bone quality, my preference is a transforaminal lumbar interbody fusion (TLIF) using local bone mixed with OsteoSponge® (Bacterin International, Inc., Belgrade, MT) and bone marrow aspirate (BMA) over BMP. BMP used through a posterior interbody approach has been reported to cause either a cystic or calcified mass causing radiculopathy.
In patients with diminished bone quality or at high medical risk, I recommend a lateral fusion using pedicle screw fixation and BMP. Pedicle screws by far provide the greatest stabilization and allow for an adequate decompression.
The Aspen device as shown in this case does not provide rigid fixation especially in torsion. I would not feel comfortable with this type of stabilization for a two-level decompression, nor would I spare the decompression in order to use the Aspen device. Pedicle screw use is very common place with an extremely low complication rate. With that said, I could see using the Aspen device in a patient with a recurrent herniated nucleus pulposus wherein the surgical procedure is a revision laminotomy.