Degenerative Disc Disease in a 30 Year-old Female
This 30 year-old female presented with low back pain that started 6 months ago. Activity makes her pain worse. She reports back pain as 8/10 and thigh pain as 5/10 without pain distal to the knee. Her Oswestry Disability Index is 50%. The patient does not have a history of trauma.
On physical examination, the patient reported low back tenderness and lumbar pain with range of motion. She is neurologically intact. 0/5 Waddell signs.
Previous treatment consisted of physical therapy, core stabilization exercises, and NSAIDs.
AP and lateral upright weight bearing images show normal alignment and disc height (Figs 1A, 1B). Lumbar flexion (Fig. 2A) and extension (Fig. 2B) images are presented. A minimal retrolisthesis at L4-L5 is indicated (Fig 2B). Lateral and axial MRI studies reveal a central disc bulge, high intensity zone, and disc desiccation at L4-L5 (Figs 3A, 3B). Discography revealed 1/10 non-concordant at L3-L4 (Fig. 4A), 10/10 concordant pain at L4-L5 (Fig. 4B), and 1/10 non-concordant at L5-S1 (Fig. 4C).
The patient has degenerative disc disease at L4-L5.
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
The patient underwent a minimally invasive TLIF (Figs 5A-D) with screws at L4 and L5 (Figs. 6A, 6C), and interbody spacer at L4-L5 (Fig. 6B).
The surgical results are very good at 6 months post-op (Figs. 7A, 7B). The patient reports no back or leg pain and her Oswestry Disability Index is 11%.
Doctor Polly presents a case of a 30 year-old female with axial low back pain with radiation to the thighs. The MRI demonstrates L4-L5 degenerative disc disease (confirmed by discography) and the flexion-extension X-rays demonstrate a minimal retrolisthesis of L4 on L5 in extension. This patient has had symptoms for 6 months.
Prior to offering any surgical treatment, I would recommend maximal conservative management with truncal strengthening, physical therapy and aqua therapy. If the patient is above ideal body weight, I would recommend weight loss. Should the patient fail all conservative measures, I would consider surgery to treat the L4-L5 segment only as a last resort.
My preference is a posterior procedure. The patient is of child-bearing age, and thus I would prefer to avoid an anterior operation (i.e. artificial disc or ALIF) through the abdominal wall musculature.
I would consider 3 surgical options: a direct lateral approach, a posterolateral fusion, or a TLIF. Of these options, I would choose a minimally invasive TLIF. In my hands, this procedure has the least amount of morbidity to the paraspinal musculature, while effectively immobilizing the abnormal segment with a high potential for fusion through the interbody space. The interbody fusion directly addresses the diseased disc and the posterior pedicle fixation addresses the minimal retrolisthesis.
Case Discussion References:
- Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN: Guidelines for the performance of lumbar fusion for degenerative disease of the lumbar spine. Part 5: correlation between radiographic and functional outcome. Journal of Neurosurgery: Spine. 2005; 2: 656-659.
- Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN: Guidelines for the performance of lumbar fusion for degenerative disease of the lumbar spine. Part 6: magnetic resonance imaging and discography for patient selection for lumbar fusion. Journal of Neurosurgery: Spine. 2005; 2: 660-667.
- Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC, Wang J, Walters BC, Hadley MN: Guidelines for the performance of lumbar fusion for degenerative disease of the lumbar spine. Part 7: intractable low back pain without stenosis or spondylolisthesis. Journal of Neurosurgery: Spine. 2005; 2:668-670.
- Mummaneni PV, Rodts GE. The Mini-Open Transforaminal Lumbar Interbody Fusion. Neurosurgery. 2005; 57(4 Suppl): 256-261.
- Wang J, Mummaneni PV, Haid RW. Current Treatment Strategies for the Painful Lumbar Motion Segment: Posterolateral Fusion Versus Interbody Fusion. Spine. 2005; 30(16 Suppl): S33-43.
- Mummaneni PV, Haid RW, Rodts GE: Lumbar Interbody Fusion: State of the Art Technical Advances. Journal of Neurosurgery: Spine. 2004; 1:24-30.
- Rodts GE, Mummaneni PV. Discogenic Back Pain: The Case for Surgery. Clinical Neurosurgery. 2004; 51:277-280.
Optimizing nonoperative care is an oft repeated mantra that we all dogmatically espouse, especially in training programs. But what does that really mean? Should patients lose their jobs because they cannot work? Should they sign up for a weight loss program that is pragmatic and doable?
New data is beginning to suggest that after 8-weeks of effort in PT, no significant additional benefit is discernible by Oswestry scores, etc. This patient had done core stabilization, a normal BMI, and was having job Impairment in spite of trying all of the appropriate nonop care. I find it a significant challenge about when to pull the trigger and do the surgery (and then there is the issue of how long does it take to get the person approved, scheduled, and into the OR).