Increasing Back and Leg Pain, Quadricep Weakness

History

The patient is a 60-year-old female with a 4-year history of increasing back pain and severe leg pain (50% back pain, 50% leg pain) with bilateral quadricep weakness (left greater than right). Her Oswestry Disability Index score is 46.

Examination

She demonstrates good coronal and sagittal balance. Forward flexion is limited to 30-degrees secondary to pain. She experiences difficulty rising from a seated position and relies on her upper extremities. Strength is 5/5, except for left quadriceps (4/5).

Images

Cropped views of standing full-length 36-inch radiographs demonstrate multi-level lumbar degenerative changes with disc height loss at L2-L3, L3-L4 and L4-L5. There are mild changes at L5-S1. Mild degenerative coronal changes are noted on the AP view. (Figures 1A, 1B)

Flexion/extension radiographs demonstrate no instability. (Figures 1C, 1D)

Figure 1A

Figure 1B

Figure 1C

Figure 1D

Mid-sagittal and multiple axial MRI demonstrate loss of disc height primarily at L2-L3, L3-L4 and L4-L5. Axial images show variable foraminal stenosis, most significant at L4-L5 on the left. (Figures 2A-2E)

Figure 2A

Figure 2B

Figure 2C

Figure 2D

Figure 2E

Diagnosis

Multi-level lumbar spondylosis with bilateral quadricep weakness (left greater than right).

Selected Treatment

The patient underwent a multi-level posterior spinal fusion / transforaminal lumbar interbody fusion with instrumentation from L2-L5. The addition of TLIFs was to increase foraminal height and regional lordosis.

One-year AP and lateral standing radiographs demonstrate a 3-level TLIF with instrumentation and restoration of disc and foraminal height, and good overall lordosis. (Figures 3A, 3B)

Figure 3A

Figure 3B

Outcome

The patient experienced complete resolution of leg pain and return to full strength. Her Oswestry Disability Index score decreased from 46 to 18 at 1-year follow-up.

Case Discussion

Doctor Kuklo's construct mirrors what I would have performed. He attained a nice restoration of lordosis, perhaps utilizing partial Smith-Petersen osteotomies, although that is not specified. I concur with the construct only spanning L2 to L5 given a normal L1-L2 disc and a relatively well-preserved height at L5-S1. The pedicle screws are nicely convergent and of sufficient length to obtain bicortical purchase.

The other treatments are inadequate in my opinion. Multilevel laminotomies may decompress the neural elements and improve quadriceps strength, but will do little to help her deformity. A full laminectomy would be considered by many to be contraindicated given her flat-back.