90% Leg Pain vs. 10% Low Back Pain: Refuses Fusion
The patient is a 46-year-old female pharmacist. She presented with a 6-month history of progressively worsening left leg pain (she rates it as a 7/10) and paresthesias. She reports only minor achy low back pain (2/10). Overall, she describes her pain as 90% left leg pain and 10% low back pain.
The patient is 5’ 6” and weighs 135 pounds. She has full range of motion with trunk flexion and extension; this does not elicit low back pain.
She has difficulty with heel walking and single-leg heel raises with her left leg.
Manual motor testing: Left ankle dorsiflexion is 4/5. Great toe extension is also 4/5.
The patient has decreased sensation in the left L5 dermatome.
Her VAS score is 7/10, and her ODI score is 40.
Previously, the patient attempted oral medications, physical therapy, chiropractic treatment, massage, and epidural steroid injections (ESIs). A left L5 transforaminal ESI resulted in 36 hours of near complete (90%) relief of the left leg pain.
She refused a spinal fusion.
Figure 1: Patient-submitted pain diagram showing left leg pain.
Figure 2: AP x-ray
Figure 3: Lateral x-ray. Note the spondylolisthesis of L4 over L5.
Figure 4: Extension and flexion x-rays. There is 2mm motion on flexion.
Figure 5: T2-weighted (left) and T1-weighted (right) MRIs demonstrating stenosis at L4-L5.
Figure 6: T2-weighted (left) and T2-weighted (right) MRIs of L4-L5 showing foraminal stenosis.
The patient was diagnosed with Grade I degenerative spondylolisthesis 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 had MIS L4-L5 decompressions, specifically:
- left L4-L5 laminotomy
- left L4-L5 foraminotomy
Figure 7: Intraoperative targeting
Figure 8: Sawbone showing level of surgery and approach
Figure 9: Intraoperative decompression
The patient reported relief of her leg pain. Her VAS score is 4/10, and her ODI score is 6.
This young female professional presents with a common surgical decision. She has personal experiences in the medical care environment and likely has read more medical-focused literature than the typical patient who only has access to patient-based public materials. The challenges are understanding and weighting scientific validity and content of patients' experienceswhether they have a professional or lay background. This interest-based experience is significant and often impacts the patient-physician interaction.
It is most prudent for the surgeon to look upon this as an educational opportunityone to assess and appreciate the patient's experiences, values, biases, and background, and take this as a window to help mature the patient's knowledge. Understanding the patient's perception and melding it with evidence-based, contemporary medical knowledge is essential to an informed patient relationship.
Spine surgical practice has come under much review due to the escalating incidence of instrumented fusion cases and because the indications for these procedures engender a wide breadth. Interpretation of literature by Richard Dayo and others of lumping multiple level fusions together for conditions as varied as tumors, ankylosing spondylitis, and deformity with axial back pain, has certainly tainted the public's opinion and awareness of this problem.
For this patient's particular condition, the SPORT trials provide excellent, high-quality information. The difference of reported "intent to treat" vs "as-treated analysis" is something that is pertinent. Discussion for this patient, as she is a pharmacist, would clearly enhance her understanding that the intent to treat would apply to 1 vs 3 pills a day more than the choices made in surgery.
An evidence-based approach to understand the natural history of patients that have neurologic deficit coupled with instability symptoms with degenerative spondylolisthesis is essential. Objectively describing the outcome expectations for non-operative therapies, such as repeat injections, the outcome of decompression alone, and the outcome of decompression at the time of fusion, is quite valid.
Having presented this in an objective evidence-based fashion emphasizing the natural history, the complications, and outcome expectations, I think as long as we feel that there is adequate clinical equipoise (ie, that these are reasonable treatment endeavors and indications within our practice), it is quite reasonable to offer both choices to the patient. This guided informed patient choice will allow the patient to determine the course of care.
My bias in the situation with a patient with progressive leg radiculopathy and instability pain is that decompressing a spondylolisthesis alone is likely the first stage in the progression of the patient's natural history, which will likely go on to include progression of listhesis and recurrent symptoms at this level. As long as the patient is understanding and accepting of this, this is certainly a reasonable, informed patient choice and one done in an ethical and contemporary fashion.