Elderly Woman with Progressive Difficulty Walking
The patient is a 91-year-old Caucasian woman. She presented with a one-year history of gradually progressive difficulty walking and severe debilitating back pain. She was otherwise very healthy and active for her age. She played golf regularly until recently—when her back and leg pain (L>R) became too severe and she was unable to walk greater than 100 feet without needing to sit down.
The patient is neurologically intact.
The patient had only temporary relief of symptoms with multiple courses of physical therapy and pain management, including epidural steroids and facet blocks.
Figures 1A, 1B, 2A, and 2B show multi-level degenerative disc disease, degenerative dextroscoliosis, and spondylolisthesis at the L4-L5 level.
Figures 3A-3F: Figures 3A, 3C, and 3E are sagittal T2-weighted MRIs. They correspond to the axial T2-weighted MRIs shown in Figures 3B, 3D, and 3F. These show spinal stenosis at the L2-L3, L3-L4, and L4-L5 level with associated spondylolisthesis at the L4-L5 level.
Multi-level spinal stenosis with spondylolisthesis and degenerative dextroscoliosis
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Minimally invasive spine (MIS) laminectomies were performed at L2-L3, L3-L4, and L4-L5.
An MIS transforaminal lumbar interbody TLIF was done at L4-L5 to insert a cage, and percutaneous pedicle screws were applied at the L4-L5 level.
An initial 3 cm incision was made on the patient’s left side and a muscle-splitting approach used to perform MIS laminectomies at the L2-L3 level first, followed by the L3-L4 then L4-L5 level. The patient’s own bone was collected for fusion material.
Lastly, an MIS TLIF plus percutaneous pedicle screw instrumentation was performed at the L4-L5 spondylolisthesis level. (See Figures 7A and 7B.)
She had less than 100 cc of estimated blood loss. Two paraspinal incisions were made approximately 3 cm in length, each allowing preservation of the normal anatomical structures of the spine.
The patient made an unremarkable recovery and was discharged on the third post-operative day. She returned to her activities of daily living a few weeks following surgery with marked improvement in gait and resolution of back and leg pain symptoms. She was able to resume her active lifestyle and golf.
Dr. Perez-Cruet presents a very challenging case in an elderly woman, who is clearly very active with worsening quality of life.
The concerns with this patient would center around her age, expectations, and medical co-morbidities. I certainly would have a very lengthy discussion about what her goals are and mitigate any unrealistic expectations. I would also consider selective nerve root blocks and at least 6 months of non-operative care prior to considering any surgical intervention, especially given the fact she is neurologically intact.
Prior to considering any surgical intervention, I would obtain a BMD to check bone quality. The sagittal MRI is also suggestive of stenosis at L5-S1, and I would have liked to know the details regarding her radiculopathy and its distribution. If she had radiculopathy extending into her feet, I would be more suspicious of L5-S1 being a symptomatic level. Also, it would be good to know if she was clinically symptomatic from the L2-L3 level, which would produce more of an anterior thigh radiculopathy.
Once the above parameters were ascertained and if she continued to be symptomatic, my choice would be to do the least amount of surgery to get the result she desires.
I would agree with decompressing the levels mentioned and would do a unilateral minimally invasive laminotomy with bilateral decompression by reaching across to the opposite side. At L4-L5, given the spondylolisthesis and coronal tilt I again would agree with decompression with stabilization and fusion. A TLIF procedure would be my choice, too.