Severe Low Back Pain in a 90-Year Old Male
The patient is a 90-year-old male with a long history of intermittent low back pain that was well-controlled for years after a L3-L5 laminectomy. During the past 9-months, the patient’s low back pain has progressed to severe and constant. Pain radiates into both legs but is greater in the right leg and worse in the thighs compared to the lower legs. The pain reduces the patient’s activity level from walking a mile daily, to now being unable to walk more than one-half block. The patient’s mood and health has deteriorated because of inactivity.
Upon exam, the patient exhibited a stiff back and increased pain with 5-degrees of lumbar extension. Palpation revealed tenderness over the lumbar paraspinal musculature, right side greater than left. Neurologically, the patient is intact.
Two orthopaedic spine surgeons determined the patient was not a surgical candidate. Pain medications were offered, but these were minimally helpful because the patient could not tolerate more than 2 tablets of hydrocodone 5-mg per day.
A pain specialist administered a series of 2 epidural steroid injections. Each injection provided mild relief for one week.
The lumbar MRI (not shown) shows extensive degenerative disc disease, degenerative joint disease, grade 1 spondylolisthesis at L5-S1, and severe bilateral neuroforaminal stenosis at L3-L4 through L5-S1.
Plain films are consistent with these findings and flexion/extension views show the spondylolisthesis to be stable (Figure 1). Figure 2 (below), an AP X-ray of T12-L4, shows extensive degenerative disc disease and degenerative joint disease.
A bone scan (Figure 3) reveals increased uptake bilaterally at the L4-S1 facets, worse on the right side.
Lumbar degenerative disc disease, degenerative disease of the lumbar facet joints, grade 1 spondylolisthesis at L5-S1, and severe, bilateral, neuroforaminal stenosis at L3-L4 through L5-S1.
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Radiofrequency facet rhizotomies were performed bilaterally at S1 leading to dennervation of the L4-L5 and L5-S1 facet joints. At the patient’s request, this was done without prior test blocks.
Ten days after treatment, the patient noted a reduction in pain. Three weeks later, he had almost resumed his previous level of activity.
The patient experienced excellent pain relief for 10 months. When pain returned, the rhizotomies were repeated with good effect. The following year, other health problems developed. Two years after the initial rhizotomies, the patient died; however, most of this time, the patient’s pain was minimal, which afforded him the ability to be active.
The treatment of low back pain is certainly a growing problem as our population ages. Issues such as osteoporosis, risk of pseudofusion, and surgical risks should all be considered.
Simple range of motion testing, as performed, was important in confirming the facets as the source of pain and target of treatment in this case.
Physical therapy alone in a motivated, previously active patient is unlikely to yield significant benefit. Spinal cord stimulation has significantly improved the treatment of low back pain with improved lead design, current control and electric field shaping, as well as peripheral field electrode placement. Intrathecal pumps have fallen out of favor among many physicians who cite declining reimbursement, especially in the Medicare population. One could also argue that the lifetime cost-benefit of either $20k implant is not justified in this aged patient.
Rhizotomies are well-suited for cases such as this and, as Dr. Richeimer points out, this option should not be overlooked. Certainly the risks of such treatment are minimal, and in this case the benefits quite impressive.