Lumbar Disc Degeneration: 2 Previous Spine Surgeries and Constant Low Back Pain

History

A 57-year-old, slightly overweight male presented with a 2 year history of progressive low back pain. It was predominantly left sided-pain, and the pain was present at all times. However, it worsens with increased activity. The patient has no leg pain, but he does have some gait difficulty due to low back pain.

Prior Treatment

In 1992, this patient had a lumbar decompression, and he did well following that surgery. In 1999, he had an L5-S1 ALIF. He did well following that surgery, as well.

To address his current low back pain, the patient has tried:

• NSAIDs
• Muscle relaxants
• Physical therapy
• Analgesics (Vicodin)
• Epidural blocks/facet blocks

These conservative measures have not brought relief.

Examination

In the physical exam, it was noted that the patient had reduced lumbar ROM in all directions. His motor response was 5/5, and sensory was intact.

The DTRs were symmetric, and the SLRs were negative.

There was palpable tenderness in his lower lumbar spine.

A discography was performed, and it was positive with concordant pain at L3-L4. It was normal at L4-L5, which was a slightly degenerated disc.

Psychosocial Issues
It's important to consider the psychosocial issues:

• The patient continues to work.
• There are no secondary gain issues.
• He does not smoke.
• He has moderate analgesic usage.
• Seems like a motivated patient.

Pre-treatment Images

Figure 1: Lateral radiograph demonstrating previous L5-S1 ALIF. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 2: AP radiograph demonstrating previous L5-S1 ALIF. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 3: Lateral flexion-extension. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 4: T1-weighted sagittal MRI demonstrating previous ALIF, a slightly degenerated disc at L4-L5, and a severely degenerated disc at L3-L4. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 5: T2-weighted sagittal MRI demonstrating same issues as in Figure 4. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Diagnosis

Severely degenerated disc at L3-L4

Selected Treatment

A TLIF with pedicle fixation was performed at L3-L4. Because the discogram showed that the L4-L5 disc was normal, it was not necessary to fuse that level.

Outcome

The patient is now 2 years post-op, and he continues to do well.

Figure 6: 1 year post-operative AP radiograph showing L3-L4 TLIFand fixation. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Figure 7: 1 year post-operative lateral radiograph. Image courtesy of Iain Kalfas, MD, and SpineUniverse.com.

Case Discussion

Stephen T. Enguidanos, MD

Orthopaedic Surgeon

Orthopaedic and Spine Surgery Center

I think the treating surgeon did a great job. The x-rays looks good. I used to do quite a few TLIFs but I have switched mostly to the lateral approach (XLIF/DLIF). My reasoning is that I do not have to worry as much about the exiting nerve, and I can get a much larger discectomy and spacer in the disc space—frequently 50 to 55mm. I usually will back them up with a lateral plate or posterior screw and rods.