Progressive Pseudoclaudication in an Elderly Man

History

The patient is a 72-year-old man with no medical co-morbidities. He presented with progressive pseudoclaudication over several years. Now, he's able to walk only 100 yards. There is no bowel/bladder dysfunction. Bilateral L3 radiculopathy was confirmed with EMG.

Examination

He is neurologically intact in all lower extremity motor groups.

• Sensation grossly intact
• Absent reflexes
• Good pulses
• ODI: 48
• VAS: Leg 7
• VAS: Back 5

Prior Treatment

Selective L3 nerve root injection offered temporary relief of pain. Three epidural steroid injections and organized physical therapy provided no relief of pain.

Pre-treatment Images

Figure 1: Severe central stenosis noted at L2-L3, L3-L4, L4-L5. Slight spondylolisthesis at L3-L4. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Figure 2: Lumbar foraminal stenosis at multiple levels. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Figure 3: Coronal MRI shows mild scoliosis (right-bender). Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Figure 4: Axial L2-L3. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Figure 5: L3-L4 showing subluxation at right L3-L4 facet joint; severe stenosis. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Figure 6: Axial L4-L5. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Diagnosis

Multiple level lumbar spinal stenosis, L3-L4 degenerative spondylolisthesis, mild degenerative scoliosis

Selected Treatment

Minimally invasive multiple level laminoforaminotomies with minimally invasive TLIF at L3-L4.

Post-treatment Images

Figure 7: TLIF L3-L4. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Figure 8: TLIF L3-L4. Image courtesy of James D. Schwender, MD, and SpineUniverse.com.

Outcome

The patient is doing great at 2 years post-op.

• ODI:16
• VAS: Leg 0
• VAS: Back 3

Case Discussion

This gentleman presents with textbook neurogenic claudication. He's been treated appropriately with non-operative management and continues to have symptoms affecting his quality of life. Selective nerve root injections and EMG nerve conduction study confirmed single-level radiculopathy.

There appears to be a mild degenerative scoliosis by MRI, but the lack of 3-foot AP and lateral x-rays make it difficult to determine spinal balance.

The post-operative x-rays do show that a one-level anterior/posterior procedure was performed at L3-L4. This has resulted in a clinical success according to the patient's VAS, which went from 7 to 0 for leg pain and 5 to 3 for back pain.

It is difficult to determine whether there has been progression of the deformity without pre-operative x-rays for comparison. It does appear from a clinical standpoint that the procedure was successful and by performing a minimally access surgery, there hasn't been significant disruption of the posterior elements that could lead to progression of the deformity.