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90% Leg Pain vs. 10% Low Back Pain: Refuses Fusion

History

The patient is a 46-year-old female pharmacist. She presented with a 6-month history of progressively worsening left leg pain (she rates it as a 7/10) and paresthesias. She reports only minor achy low back pain (2/10). Overall, she describes her pain as 90% left leg pain and 10% low back pain.

Examination

The patient is 5’ 6” and weighs 135 pounds. She has full range of motion with trunk flexion and extension; this does not elicit low back pain.

She has difficulty with heel walking and single-leg heel raises with her left leg.

Manual motor testing: Left ankle dorsiflexion is 4/5. Great toe extension is also 4/5.

The patient has decreased sensation in the left L5 dermatome.

Her VAS score is 7/10, and her ODI score is 40.

Prior Treatment

Previously, the patient attempted oral medications, physical therapy, chiropractic treatment, massage, and epidural steroid injections (ESIs). A left L5 transforaminal ESI resulted in 36 hours of near complete (90%) relief of the left leg pain.

She refused a spinal fusion.

Pre-treatment Images

fig1 Roh 46yo Female Pharmacist Decompression Pre-op Pain Diagram

Figure 1: Patient-submitted pain diagram showing left leg pain.

 

fig2 Roh 46yo Female Pharmacist Decompression Pre-op AP X-rayFigure 2: AP x-ray

 

fig3 Roh 46yo Female Pharmacist Decompression Pre-op Lateral X-rayFigure 3: Lateral x-ray. Note the spondylolisthesis of L4 over L5.

 

fig4 Roh 46yo Female Pharmacist Decompression Pre-op Flexion Extension X-raysFigure 4: Extension and flexion x-rays. There is 2mm motion on flexion.

 

fig5 Roh 46yo Female Pharmacist Decompression Pre-op Weighted MRIsFigure 5: T2-weighted (left) and T1-weighted (right) MRIs demonstrating stenosis at L4-L5.

 

fig6 Roh 46yo Female Pharmacist Decompression Pre-op L4-L5 MRIsFigure 6: T2-weighted (left) and T2-weighted (right) MRIs of L4-L5 showing foraminal stenosis.

Diagnosis

The patient was diagnosed with Grade I degenerative spondylolisthesis at L4-L5.

Suggest Treatment

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Selected Treatment

The patient had MIS L4-L5 decompressions, specifically:

  • left L4-L5 laminotomy
  • left L4-L5 foraminotomy

Intraoperative Images

fig7 Roh 46yo Female Pharmacist Decompression Intra-op TargetingFigure 7: Intraoperative targeting

 

fig8 Roh 46yo Female Pharmacist Decompression Intra-op Sawbone TargetingFigure 8: Sawbone showing level of surgery and approach

 

fig9 Roh 46yo Female Pharmacist Decompression Intra-op PictureFigure 9: Intraoperative decompression

Outcome

The patient reported relief of her leg pain. Her VAS score is 4/10, and her ODI score is 6.

Case Discussion

This young female professional presents with a common surgical decision. She has personal experiences in the medical care environment and likely has read more medical-focused literature than the typical patient who only has access to patient-based public materials. The challenges are understanding and weighting scientific validity and content of patients' experiences—whether they have a professional or lay background. This interest-based experience is significant and often impacts the patient-physician interaction.

It is most prudent for the surgeon to look upon this as an educational opportunity—one to assess and appreciate the patient's experiences, values, biases, and background, and take this as a window to help mature the patient's knowledge. Understanding the patient's perception and melding it with evidence-based, contemporary medical knowledge is essential to an informed patient relationship.

Spine surgical practice has come under much review due to the escalating incidence of instrumented fusion cases and because the indications for these procedures engender a wide breadth. Interpretation of literature by Richard Dayo and others of lumping multiple level fusions together for conditions as varied as tumors, ankylosing spondylitis, and deformity with axial back pain, has certainly tainted the public's opinion and awareness of this problem.

For this patient's particular condition, the SPORT trials provide excellent, high-quality information. The difference of reported "intent to treat" vs "as-treated analysis" is something that is pertinent. Discussion for this patient, as she is a pharmacist, would clearly enhance her understanding that the intent to treat would apply to 1 vs 3 pills a day more than the choices made in surgery.

An evidence-based approach to understand the natural history of patients that have neurologic deficit coupled with instability symptoms with degenerative spondylolisthesis is essential. Objectively describing the outcome expectations for non-operative therapies, such as repeat injections, the outcome of decompression alone, and the outcome of decompression at the time of fusion, is quite valid.

Having presented this in an objective evidence-based fashion emphasizing the natural history, the complications, and outcome expectations, I think as long as we feel that there is adequate clinical equipoise (ie, that these are reasonable treatment endeavors and indications within our practice), it is quite reasonable to offer both choices to the patient. This guided informed patient choice will allow the patient to determine the course of care.

My bias in the situation with a patient with progressive leg radiculopathy and instability pain is that decompressing a spondylolisthesis alone is likely the first stage in the progression of the patient's natural history, which will likely go on to include progression of listhesis and recurrent symptoms at this level. As long as the patient is understanding and accepting of this, this is certainly a reasonable, informed patient choice and one done in an ethical and contemporary fashion.

Community Case Discussion (5 comments)

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


That was a very long explanatiion of a very simple problem.

She will be back with worsening deformity and leg pain. She needed time spent with her explaining her condition rather than an operation that has at best provided temporary relief and at worse accelerated the deterioration of her deformity. She already has lateral olisthesis as well as sagittal instability at L4/5. At 46, with the beginnings of a de novo lumbar scoliosis, decompression alone will only provide temporary relief.

One could argue that you had the opportunity to arrest the progression of scoliosis with a TLIF if you had horizontalised L4. Instead, the next step will be a forwards rotation of the left side of L4 on L5 due to subluxation through the facet joint. The left L4/5 facet joint is already overloaded being in the concavity of the fractional lower curve - now it has been further weakened by the decompression. The decompression will only accelerate progression of the deformity with rotatory olisthesis resulting.

I would be fascinated to see her erect X-rays in 5 years.

The flexion and extension views do not show instability and if can do and if one is able to do a good decomressiom with producing instability the pt should a good result as she has sig stenosis 85% of the time. Blood loss should be small and recovery quick, I encourge these pys to walk as much as they can and starting on day one. The need for further surgery at this level is small however at another level at a later date the need may be larger as the natural history of spinal stenosisi is that adjancet levels fregnently become involved.

The flexion and extension views do not show instability and if can do and if one is able to do a good decomressiom with producing instability the pt should a good result as she has sig stenosis 85% of the time. Blood loss should be small and recovery quick, I encourge these pys to walk as much as they can and starting on day one. The need for further surgery at this level is small however at another level at a later date the need may be larger as the natural history of spinal stenosisi is that adjancet levels fregnently become involved.

I think if one is to do a decompression alone after properly informing patient of possibility of future fusion, it is most important to do the least amt. of bone and ligament removal necessary to decompress the L5 lateral recess. It is usu not necessary or advantageous to do a foraminotomy since the L4 root is usu not involved. Whether this is accomplished MIS with tubes or a 2 inch skin incision makes no difference. If they have L4 pain (which this pt like most apparently does not) then an L4 foraminotomy is done and a TLIF is strongly recommended.

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