Lumbar Herniation with Radiculopathy

History

The patient is a 42-year-old male with a 10-week history of left leg and back pain (60% leg pain, 40% back pain). He described his pain as posterior left thigh and calf, and posterior ankle. He cannot sit or sleep. Otherwise, he is healthy and is the owner-operator of a small trucking company.

Examination

He is a healthy male with good coronal and sagittal balance. He has mild calf atrophy and positive straight leg raise on the left.

Images

AP and lateral standing lumbar radiographs (Figures 1A, 1B) demonstrate mild loss of disc height at L3-L4, L4-L5 and L5-S1 with overall good alignment.

Figure 1A. AP radiograph

Figure 1B. Lateral standing lumbar radiograph

Mid-sagittal and axial images (Figures 2A, 2B) demonstrate a large left paracentral disc herniation at L5-S1 and moderate degenerative changes at L4-L5 (sagittal view).

Figure 2A

Figure 2B

Diagnosis

The patient was diagnosed with a herniated nucleus pulposus with left S1 radiculopathy and back pain.

Selected Treatment

Left L5-S1 transforaminal steroid injection therapy failed to effectively treat the patient's symptoms. He underwent a left L5-S1 microscopic discectomy utilizing tubular retractors and returned to work (supervising) at 2-weeks postoperative doing well. However, at 6-weeks postoperative, he complained of severe recurrent left leg pain in a similar distribution and returned to the clinic. (Figure 3)

Figure 3. Sagittal MRI at 6-weeks after microdiscectomy shows recurrent disc herniation.

He was treated with a revision microscopic discectomy at L5-S1 with complete resolution of symptoms. MRIs demonstrate appearance of the disc postoperative. (Figures 4A, 4B)

Figure 4A. Post-revision

Figure 4B.Axial MRI, post-revision

Note loss of disc height at L5-S1 without instability on flexion-extension radiographs. (Figures 5A-5D)

Figure 5A

Figure 5B

Figure 5C

Figure 5D

Outcome

At 1-year follow-up, the patient was doing well, without leg pain, but complaining of mild increasing back pain.

Case Discussion

This is an interesting case and fortunately, not a common scenario encountered. The patient initially presented with a unilateral S1 radiculopathy with minority of low back pain. The goal of the initial surgery, after failure of epidural steroid trial, was to decompress the nerve root and allow the patient return to work in a timely manner. Unfortunately, he developed a recurrent disc herniation at L5-S1 which can occur in 3-11% of postoperative patients after lumbar discectomy. (1-6)

Repeat imaging in the peri-operative period with MRI can be difficult in that the MRI features of the presenting disc may be present on delayed images. This can make diagnosis confusing but, in the appropriate clinical setting, the diagnosis is easily established. With a recurrent herniation, the treatment option of no treatment, epidural steroid therapy, decompression, and decompression and fusion must be contemplated. This patient had no instability on flexion/extension film and further collapse of the disc space at L5-S1 with a minority of low back pain.

With a severe radiculopathy, typically I will attempt a transforaminal epidural steroid injection at the site of the recurrent disc herniation to see how the patient responds prior to a resurgical approach. If the patient has complete or significant relief, then they can be followed clinically. If there is no to little response, then a repeat discectomy is performed. The clinical response to a repeat surgery is excellent with the relief similar to initial surgeries. (7)

With repeated disc herniation, the patient has collapsed his disc space and stiffened the spinal segment. Due to the limited amount of back pain and no instability on his imaging, the patient is likely to gain significant benefit with an arthrodesis procedure.

References:
1. Hakkinen A. Kiviranta I. Neva MH. Kautiainen H. Ylinen J. Reoperations after first lumbar disc herniation surgery; a special interest on residives during a 5-year follow-up. BMC Musculoskeletal Disorders. 8:2, 2007.

2. Jackson RK. The long-term effects of wide laminectomy for lumbar disc excision: a review of 130 patients. J Bone Joint Surg Br. 1971;53:609-16.

3. O'Sullivan MG, Connolly AE, Buckley TF. Recurrent lumbar disc protrusion. Br J Neurosurg. 1990;4:319-25.

4. Thomalske G, Galow W, Ploke G. Operation results in 2000 cases of lumbar intervertebral disk lesions. Munch Med Wochenschr. 1977;119:1159-64.

5. Ebeling U, Kalbarcyk H, Reulen HJ. Microsurgical reoperation following lumbar disc surgery: timing, surgical findings, and outcome in 92 patients. J Neurosurg. 1989;70:397-404.

6. Connolly ES. Surgery for recurrent lumbar disc herniation. Clin Neurosurg. 1992;39:211-6.

7. Papadopoulos EC, Girardi FP, Sandhu HS, Sama AA, Parvataneni HK, O'Leary PF, Cammisa FP Jr. Outcome of revision discectomies following recurrent lumbar disc herniation. Spine. 31(13):1473-6, 2006.