Lumbar Degenerative Disc Disease in a 37-year-old Male

History

The patient is a 37-year-old right handed male who underwent L4-L5 microendoscopic discectomy two years ago. He was doing very well until he fell down a flight of stairs. He presents with two weeks of new right lower extremity pain in the L5 distribution.

Examination

The patient is observed to be lying flat on the examination table, with both legs flexed at the hip and knees. The examination reveals normal strength and reflexes, decreased sensation to pinprick in the right second and third toes, negative Babinski's sign, and antalgic gait.

Prior Treatment

Bed rest, narcotics, and muscle relaxers.

Images

Figure 1. Sagittal T2 MRI

Figure 2. T1 axial MRI with gadolinium

Figure 3. T1 with gadolinium

Diagnosis

• Status post right L4-L5 microendoscopic discectomy
• Recurrent right L4-L5 disc herniation
• Right L5 radiculopathy

Selected Treatment

Because of his extreme pain, and inability to stand and walk, the patient requested surgery as soon as possible. A repeat right L4-L5 microendoscopic discectomy was performed, through which a large disc fragment was identified and removed.

Outcome

The patient's radiculopathy resolved immediately and he was able to return to work one-week later. One-year postop, he reports mild intermittent back pain, but he is not limited in his activity.

Case Discussion

There are several positive caveats to be drawn from this case. The fact that the patient did well after his first discectomy, with resolution of pain and return to function, may be a good predictor of success if treatment is needed again in the future. Next, the patient presents with a new injury and classic finding, on imaging and exam, of a recurrent herniated disc.

The patient was not complaining of chronic back pain and was functioning well until the second herniation occurred. A repeat microdiscectomy, rather than a fusion, is the appropriate surgical intervention if a patient fails a course of nonoperative care. Most surgeons would consider a fusion if a third herniation occurs.