SpineUniverse Case Study Library

Severe Sciatica with Lumbar Spinal Stenosis and Cyst

History

The patient is a 57-year-old male who presented with long-standing bilateral claudication and more recent severe, left-side sciatica. He has some back pain, but the leg pain is much worse.

preoperative VAS: back 2, right leg 3, left leg 8His medical history includes hypercholesterolemia, hypothyroidism, and obesity. He is 5’11”, weighs 280 pounds and his BMI is 40.

Examination

  • Mild right ankle weakness
  • Extensor hallucis longus weakness
  • Positive straight-leg raise
  • Other neurological signs intact

Pretreatment Imaging

Figures 1A-1C (below), show L4-L5 lumbar spinal stenosis, severe facet disease, low grade spondylolisthesis, and left synovial cyst.

preoperative lateral MRI denoting L4-L5 lumbar spinal stenosis, facet disease, spondylolisthesis, and synovial cystFigure 1A

sagittal MRI with contrast denoting L4-L5 lumbar spinal stenosis, facet disease, spondylolisthesis, and synovial cystFigure 1B

axial MRI with contrast denoting L4-L5 lumbar spinal stenosis, facet disease, spondylolisthesis, and synovial cystFigure 1C

Prior Treatment

Extensive nonoperative treatments, including spinal injections have not provided significant or lasting benefit.

Diagnosis

L4-L5 spinal stenosis, severe facet disease, low grade spondylolisthesis, left side synovial cyst

Suggest Treatment

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Selected Treatment

The patient underwent minimally invasive ligament-sparing bilateral decompression from the right side with resection of left synovial cyst.

The procedure involved tubular bilateral decompression utilizing an Orthozon retractor (length: 95mm) and extended view (Top: 18mm; Bottom: 24mm).

The video illustrates:

  1. Removal of soft tissue and exposure of the right lamina and right medial facet
  2. Drilling of the lamina and facet
  3. Removal of soft tissue and exposure of contralateral (left) lamina and facet
  4. Drilling of contralateral lamina and facet
  5. Removal of the lamina and exposure of the ligamentum flavum
  6. Dural exposure starting at the midline
  7. Dissection of contralateral ligament and cyst utilizing a Penfield #4
  8. Removal of the contralateral ligament and cyst
  9. Removal of the ipsilateral ligament
  10. View through a tubular retractor

Operative time was 80 minutes. Blood loss was 20cc. The patient was released home 2 hours after surgery.

Outcome

At the patient's 3 month postop appointment, he reported his right and left leg pain to be much improved.

postop VAS: back 2, right leg 0, left leg 1

Case Discussion

Dr. Aferzon has presented an interesting case of a morbidly obese male with symptomatic lumbar spinal stenosis, spondylolisthesis and synovial cyst. This particular triad of symptoms is very common, yet the treatment options are so diverse. Some propose decompression while others would advocate for fusion to prevent progression of listhesis. This case, in my opinion, highlights one of the pillars of minimally invasive spine surgery (MIS), the “non-destabilizing laminectomy.

Surgeons who utilize MIS techniques know a posterior tension band- and ligament-preserving decompression is feasible and highly effective. The ability to decompress bilaterally through a unilateral MIS approach is equally effective, and represents a powerful tool for not only laminectomies but MIS TLIF cases as well. The author is to be congratulated for the excellent technical and clinical outcome.

Note: patients should be counseled that an MIS decompression, though highly effective and safe, does not necessarily obviate the potential need for subsequent fusion at that level.

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