Construction Worker with Increasing Low Back Pain and Bilateral Leg Pain
A 42-year-old male construction worker presents with a 2-year history of worsening low back pain and bilateral (L>R) lower extremity radiation in L3 and L4 dermatomal distributions. The patient reports right leg weakness (ankle dorsiflexion) and symptoms consistent with neurogenic claudication.
In the physical exam, the patient, who is 5’10” and weighs 205 pounds, was found to have limited extension. He also has difficulty with heel walking bilaterally, and deep-seated squats on the right.He has 4/5 bilateral ankle dorsiflexion and a positive right femoral stretch test.
EMG shows subacute bilateral L4 radiculopathy.
On the VAS, he is 7/10—exacerbated with prolonged standing, walking, and lifting, and his ODI score is 70.
Previously, the patient attempted oral medications, physical therapy, massage, and epidural steroid injections (ESI). Bilateral L4 transforaminal ESIs resulted in temporary (80%) improvement in leg pain.
Figure 1: Patient-submitted pain diagram showing bilateral (L>R) lower extremity radiation.
Figure 2: AP and lateral x-rays
Figure 3: T2-weighted (left) and T1-weighted (right) MRIs showing central stenosis at L3-L4.
Figure 4: MRI showing left foraminal stenosis at L4.
Figure 5: MRI showing right foraminal stenosis at L3 and L4.
Figure 6: MRI of L3-L4 showing foraminal stenosis.
Figure 7: MRI of L4-L5 showing bilateral foraminal stenosis.
The patient was diagnosed with L3-L4 central stenosis, right foraminal stenosis at L3-L4, and bilateral foraminal stenosis 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 MIS L3-L4 and L4-L5 decompressions. The patient had:
- right L3-L4 laminotomy
- left L4-L4 laminoplasty
- right L3-L4 foraminotomy
- bilateral L4-L5 foraminotomies
Figure 8: Intraoperative targeting
Figure 9: Sawbone showing level of surgery and approach
Figure 10: Intraoperative decompression
The patient reported relief of his low back pain, as well as his leg pain. His VAS score is 0 (pre-op VAS was 7), and his ODI score is 2 (pre-op ODI was 70).
The treating surgeon presents a case of a construction worker who has had progressive worsening of back and leg pain. The patient has pretty disabling symptoms with a VAS score of 7/10.
In this light, depending on the data above, my discussion with the patient regarding the role of surgery to intervene to help to improve the natural history of this disease is reasonable. Let's also comment upon this surgeon to have a realistic discussion with the patient regarding outcome expectations and long-term durability from a vocational standpoint.
In this patient's case, he has what appeared to be long-standing subacute changes in endplate apoptosis, which are most typically seen in spectrum instability syndrome as described by I. McNab. The cupping of the endplate at L3-L4 and the lateral osteophytes at L2-L3 and L4-L5 are indicative of chronic adaptive changes related to degenerative apoptosis of the lumbar spine.
This patient also has a pseudo stabilization of L5 to the sacrum, evident on the left by the pseudo joint at the sacral ala right by the very large transverse process, as well as the abnormally well-hydrated or semi-protected disc at L5-S1. In this scenario, the patient actually has a four-motion segment spine, and of course, is undergoing accelerated degenerative changes.
This patient, who is 5'10" and 205 pounds, likely has a mesomorphic physique as evident with well-muscled MR axial sections. Nevertheless, he is someone who would benefit from an ongoing core stabilization program.
The decisions to proceed with surgical intervention appropriately needs to focus on the patient's dominant symptomatology, which in this case was radiculopathy secondary to foraminal stenosis.
Appropriate focused discussion regarding outcome expectations, natural history, treated vs untreated, and relative complications is pertinent to developing a relationship with a patient with informed choice. Allowing the patient to make this decision when he feels he is of sufficient disability to benefit from the procedure would be of substantial help in this patient's choice.