SpineUniverse Case Study Library

Construction Worker with Increasing Low Back Pain and Bilateral Leg Pain


A 42-year-old male construction worker presents with a 2-year history of worsening low back pain and bilateral (L>R) lower extremity radiation in L3 and L4 dermatomal distributions. The patient reports right leg weakness (ankle dorsiflexion) and symptoms consistent with neurogenic claudication.


In the physical exam, the patient, who is 5’10” and weighs 205 pounds, was found to have limited extension. He also has difficulty with heel walking bilaterally, and deep-seated squats on the right.He has 4/5 bilateral ankle dorsiflexion and a positive right femoral stretch test.

EMG shows subacute bilateral L4 radiculopathy.

On the VAS, he is 7/10—exacerbated with prolonged standing, walking, and lifting, and his ODI score is 70.

Prior Treatment

Previously, the patient attempted oral medications, physical therapy, massage, and epidural steroid injections (ESI). Bilateral L4 transforaminal ESIs resulted in temporary (80%) improvement in leg pain.

Pre-treatment Images

fig1 Roh 42yo Male Construction Worker Decompression Pre-op Pain DiagramFigure 1: Patient-submitted pain diagram showing bilateral (L>R) lower extremity radiation.


fig2 Roh 42yo Male Construction Worker Decompression Pre-op AP and Lateral X-raysFigure 2: AP and lateral x-rays


fig3 Roh 42yo Male Construction Worker Decompression Pre-op Weighted MRIsFigure 3: T2-weighted (left) and T1-weighted (right) MRIs showing central stenosis at L3-L4.


fig4 Roh 42yo Male Construction Worker Decompression Pre-op L4 MRIFigure 4: MRI showing left foraminal stenosis at L4.


fig5 Roh 42yo Male Construction Worker Decompression Pre-op L3 and L4 MRIFigure 5: MRI showing right foraminal stenosis at L3 and L4.


fig6 Roh 42yo Male Construction Worker Decompression Pre-op Axial L3-L4 MRIFigure 6: MRI of L3-L4 showing foraminal stenosis.


fig7 Roh 42yo Male Construction Worker Decompression Pre-op Axial L4-L5 MRIFigure 7: MRI of L4-L5 showing bilateral foraminal stenosis.


The patient was diagnosed with L3-L4 central stenosis, right foraminal stenosis at L3-L4, and bilateral foraminal stenosis at L4-L5.

Suggest Treatment

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Selected Treatment

The patient underwent MIS L3-L4 and L4-L5 decompressions. The patient had:

  • right L3-L4 laminotomy
  • left L4-L4 laminoplasty
  • right L3-L4 foraminotomy
  • bilateral L4-L5 foraminotomies

Intraoperative Images

fig8 Roh 42yo Male Construction Worker Decompression Intra-op TargetingFigure 8: Intraoperative targeting


fig9 Roh 42yo Male Construction Worker Decompression Intra-op Sawbone TargetingFigure 9: Sawbone showing level of surgery and approach


fig10 Roh 42yo Male Construction Worker Decompression Intra-op PictureFigure 10: Intraoperative decompression


The patient reported relief of his low back pain, as well as his leg pain. His VAS score is 0 (pre-op VAS was 7), and his ODI score is 2 (pre-op ODI was 70).

Case Discussion

The treating surgeon presents a case of a construction worker who has had progressive worsening of back and leg pain. The patient has pretty disabling symptoms with a VAS score of 7/10.

In this light, depending on the data above, my discussion with the patient regarding the role of surgery to intervene to help to improve the natural history of this disease is reasonable. Let's also comment upon this surgeon to have a realistic discussion with the patient regarding outcome expectations and long-term durability from a vocational standpoint.

In this patient's case, he has what appeared to be long-standing subacute changes in endplate apoptosis, which are most typically seen in spectrum instability syndrome as described by I. McNab. The cupping of the endplate at L3-L4 and the lateral osteophytes at L2-L3 and L4-L5 are indicative of chronic adaptive changes related to degenerative apoptosis of the lumbar spine.

This patient also has a pseudo stabilization of L5 to the sacrum, evident on the left by the pseudo joint at the sacral ala right by the very large transverse process, as well as the abnormally well-hydrated or semi-protected disc at L5-S1. In this scenario, the patient actually has a four-motion segment spine, and of course, is undergoing accelerated degenerative changes.

This patient, who is 5'10" and 205 pounds, likely has a mesomorphic physique as evident with well-muscled MR axial sections. Nevertheless, he is someone who would benefit from an ongoing core stabilization program.

The decisions to proceed with surgical intervention appropriately needs to focus on the patient's dominant symptomatology, which in this case was radiculopathy secondary to foraminal stenosis.

Appropriate focused discussion regarding outcome expectations, natural history, treated vs untreated, and relative complications is pertinent to developing a relationship with a patient with informed choice. Allowing the patient to make this decision when he feels he is of sufficient disability to benefit from the procedure would be of substantial help in this patient's choice.

Community Case Discussion (3 comments)

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

Without trying to sound over-simplistic, I'd have performed a right L3/4 discectomy for this patient. The lateral recess stenosis at L4/5 looks subtle. The red rings make evaluation of the exit foraminae a little tricky, but to my eye, the exiting nerves aren't compressed at L4/5.
How long did the MIS 2 level decompression take and how long was the recovery period?

I would agree that this man appears to have motion segment instability, with a probable contribution from the pseudarthrosis between the TP of L5 on the left (and possibly on the right as well) stiffening the L5/S1 level . There is wedging of the L3/4 disc as well as anterior and lateral lipping of the adjacent endplates as mentioned above. In addition, he is probably slightly kyphotic through this level.

In my opinion the stenosis is secondary to the instability and while decompression alone has achieved a good result in the short term, I suspect that he may have further problems at this level in future and may ultimately require decompression and fusion with restoration of lumbar lordosis.

To avoid or postpone this outcome core strengthening and activity +/- work modification will be necessary.

I agree that the obvious anatomic pathology is the large right lateral L3-4 disc herniation causing severe foraminal stenosis. Although this does not explain all of his reported symptoms it does explain his motor deficit and could easily be treated with an extraforaminal discectomy done open or MIS. His pain diagram does not actually indicate typical L 3 or L4 dermatomal pain and I am not very impressed with either central stenosis at L3-4 or foraminal stenosis at L4-5 so I wonder how important those portions of the decompression were to the good outcome.


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