Leg Pain and Sagittal Imbalance

Patient History

The patient is a 59-year-old female with severe leg pain and sagittal imbalance. No prior surgery. She has subluxations at L3-L4, fixed tilt at L4-L5, and disc degeneration at all lumbar levels as documented by MRI. Spinal stenosis is noted at L2-L3, L3-L4, and L4-L5.

Examination

The patient is neurologically intact. She's very pitched forward when she stands and walks. She can only walk short distances without having to stop secondary to leg pain, weakness, and numbness.

Images

Figures 1A and 1B are standing long cassette pre-operative radiographs that demonstrate sagittal imbalance and positive sagittal balance.

Figure 1A. AP x-ray; curvature in degrees is noted

Figure 1B. Lateral x-ray

Figure 2. AP x-ray; curvature in degrees noted

The patient is 62-1/2" tall and weighs 175 pounds. Clinical pre-operative photos. (Figures 3A, 3B)

Figure 3A

Figure 3B

Axial MRIs show substantial spinal stenosis at L2-L3, L3-L4, and L4-L5. (Figures 4A, 4B, 4C)

Figure 4A

Figure 4B

Figure 4C

Figure 5. Pre-operative SRS-22 broken into domains; 25 is a normal score in each domain. The patient has significant pain, function, self-image, and mental health pathology and limitations.

Diagnosis

Spinal stenosis at 3 levels, de novo degenerative scoliosis with fixed titled L4-L5 with rotatory subluxation at L3-L4, and fixed sagittal imbalance.

Selected Treatment

The patient underwent decompression at L2-L3, L3-L4, and L4-L5. Anterior lumbar interbody fusion (ALIF) was performed through a perimedian approach at L3-L4, L4-L5, L5-S1 with posterior instrumented fusion T11-sacrum and pelvis.

Images and clinical photos are 3+10 years postoperative. (Figs. 6A, 6B, 7A, 7B)

Figure 6A

Figure 6B

Sagittal imbalance much improved. (Figures 7A, 7B)

Figure 7A

Figure 7B

Figure 8. Oswestry scores

Outcome

The patient reports substantial improvement in her back pain and sagittal imbalance. She is able to walk unlimited distances. Before surgery, could only walk two blocks without having to stop.

Case Discussion

This patient is a 59-year-old with a chief complaint of leg pain, likely related to severe multilevel lumbar spinal stenosis at L2-L5 in the setting of significant global degenerative changes in her lumbar spine, degenerative scoliosis, and coronal and sagittal imbalance.

The most reasonable surgical treatment option for this patient includes decompression to address her major areas of stenosis and then a reconstruction to preserve this decompression and address her overall imbalance issues. I would favor an anterior spinal fusion first at the three lowest lumbar levels with contouring of the structural allograft to restore the lumbar lordosis. BMP would be used to augment the anterior graft at a dose of approximately 3-4mg per level. Under the same anesthetic, I would instrument and fuse T11-sacrum / ilium posteriorly with decompression L2-L5. Wide Ponte-type osteotomies or releases would be employed throughout the instrumented segments to maximize the three-dimensional reconstruction. Local bone would be used posteriorly augmented with crushed cancellous allograft. I would consider using additional BMP posteriorly at the lower levels at a similar dose to that used anteriorly. Further, I would consider using powdered antibiotic mixed with the bone graft posteriorly given the not insignificant risk of postoperative deep posterior wound infection.