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Lumbar Failed Back Surgery Post Laminectomy

History

The patient is a 69-year-old male celebrity who underwent L2-L5 lumbar laminectomies in 2015 by an orthopaedic surgeon. Since the surgery, he feels he is “getting worse,” and rates his lower back pain as 10/10. He has bilateral leg pain (left greater than right).

Examination

  • Bilateral leg pain; left greater than right.
  • Left leg pain and numbness in a L3 distribution.
  • The patient’s ability to walk has deteriorated, limiting his gait. He relies on a walker.
  • His ability to stand is limited causing him to be unemployed.
  • Sitting provides some relief.
  • He is on chronic narcotic medications with a steadily increasing dose.

Prior Treatment

  • Regular lumbar epidural injections, which provided relief the past 10 years, are no longer effective for managing back and leg pain.
  • The patient reports his symptoms have worsened since radiofrequency ablation that was performed by a pain medicine specialist.

Pre-treatment Images

X-rays demonstrate the prior lumbar laminectomies (L2-L5) and lumbar kyphosis (Fig. 1)

lateral and posterior x-rays, prior lumbar laminectomies, lumbar kyphosisFigure 1. X-rays demonstrate the prior lumbar laminectomies and lumbar kyphosis.

Lumbar CT scans show mild scoliosis and severe degenerative changes (Fig. 2).

Lumbar CT scans show mild scoliosis and severe degenerative changesFigure 2. Lumbar CT scans show mild scoliosis and severe degenerative spinal changes.

The lumbar MRIs show lumbar kyphosis, prior laminectomies at L2-L5, and diffuse degenerative changes at the L1-L5 levels (Fig. 3).

The lumbar MRIs show lumbar kyphosis, prior laminectomies at L2-L5, and diffuse degenerative changes at the L1-L5 levelsFigure 3. MRIs demonstrate lumbar kyphosis, prior laminectomies at L2-L5, and diffuse degenerative changes at the L1-L5 levels.

Diagnosis

Failed lumbar spine surgery.

Suggest Treatment

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Selected Treatment

Using neuronavigation and intraoperative CT, surgical treatment involved:

  • Posterior lumbar interbody fusion (PLIF) at L4-L5
  • Posterolateral arthrodesis at L1-L2, L2-L3, L3-L4
  • Posterior lumbar instrumentation at L1, L2, L3, L4, L5

Post-operative Imaging

Post-operative x-rays show the L1-L5 fusion and instrumentation (Fig. 4)

post-operative x-rays show spinal instrumentation and fusion at L1-L5Figure 4. Post-operative x-rays demonstrate spinal instrumentation and fusion at L1-L5.

Outcome

The patient was discharged to a rehabilitation facility where he stayed for 2 weeks.

Post-operatively, all his leg pain has completely resolved. He continues to have some lower back pain, although he feels it’s much improved compared to before the surgery. His ability to walk and stand are greatly improved, and he no longer requires a walker or cane. He is off all narcotic pain medications and has returned to work as a broadcaster.

Case Discussion

The author is to be congratulated on the successful outcome of a challenging case. The case brings several issues forth in a population that always is a challenge—post-laminectomy low back pain with multilevel degenerative disc disease.

Localizing the pain generators is sometimes not possible but a search has to be made for gross instability, micro instability, sagittal imbalance and persisting stenosis. The solution worked very well but raises a few questions all of which have bitten me in the past:

1. How did the surgeon arrive at the decision to perform this surgery in this patient? Was there dynamic instability?

2. Should a long fusion stop at L1 or L5?

3. Was the degree of correction adequate given the persisting upper lumbar kyphosis?

4. How else could this have been done (laterally, anteriorly or combination)?

Not all these decisions are easy and there are many solutions, including spinal cord stimulation. There is no right answer and only challenging solutions. I’m sure the comments will give half a dozen ways of correcting this. In the end, the author should again be congratulated on an excellent outcome in a challenging subset of patients.

Community Case Discussion (2 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


Patient never had a proper decompression with the first surgery. I hope he got one with the second.

Great case study which highlights a very common problem. As a non-surgeon, I have always been impressed by the great variety of "laminectomy" options. Some surgeons try to preserve the spinous processes and supra/interspinous ligaent complex with the hopes of maintaining greater stability over the long term. Limited laminectomy, resection of ligamentum flavum, and even foraminoplasty are all options that preserve these important dorsal structures, while providing some decompression. At times "just a little more breathing room" may provide a good result with less morbidity, but with the knowledge that long term durability may be . I not as good. wonder how long term outcomes compare.

The other issue regards radiofrequency neurotomy of the dorsal ramus in order to deinnervate the facet joint, and thereby lessen arthritic back pain. Even among pain specialists, and in the literature, there is some controversy regarding this approach. It is well known that this nerve provides muscular innervation to the local multifidus muscle and paraspinal EMG was a tool previously used to confirm technical success. This will by definition weaken one of the lumbar muscular stabilizers, and perhaps add to instability problems down the road, especially if performed at multiple levels. Our practice uses PRP as a lower risk option for palliating lumbar facet arthritic pain, with similar durability and efficacy.

At some point, structural failure and deformity requires surgical correction and I applaud the successful effort.

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