Refractory Lumbar Back Pain in a 40-Year-Old Female

History

A 40-year-old female presented to our clinic with refractory back pain for 4 years. She has no past medical history or history of trauma.

• No leg pain or radicular symptoms
• Pain is 8/10 in severity
• On chronic opioid therapy at night to help sleep
• Ability to perform activities of daily living are diminishing
• Oswestry Disability Index is 40

Pain characteristics: The patient's pain is worse when sitting, standing and bending forward. Pain is present throughout the day and does not worsen at night. She is very resistance to taking opioids, but will take an opioid at night to help sleep.

Psychosocial characteristics: The patient has no personal or family history of depression or other mental illness. She does not use tobacco and is currently employed.

Examination

• 5/5 strength throughout all muscle groups
• Sensation intact in all dermatomes to all modalities
• Pain with flexion and extension of the lumbar spine

Prior Treatment

Extensive attempts at physical therapy, chiropractic, acupuncture, and multiple interventional procedures, including epidural steroid injections and radiofrequency ablation—none were effective. Unfortunately, the physical therapy and RFA records are not accessible, as these therapies were performed prior to evaluation in our clinic.

Pre-Treatment Imaging

Lumbar MRI shows severe disc degeneration at L5-S1 (Figures 1, 2).

Figure 1. Lumbar MRI shows severe disc degeneration at L5-S1.

Figure 2. Axial lumbar MRI shows severe disc degeneration at L5-S1.

CT scan of the lumbar spine also shows severe disc degeneration at L5-S1 (Figures 3, 4).

Figure 3. CT scan of the lumbar spine also shows severe disc degeneration at L5-S1.

Figure 4. Axial CT scan of the lumbar spine also shows severe disc degeneration at L5-S1.

Pre-operative scoliosis x-ray shows lumbar lordosis of 56-degrees, pelvic incidence of 66-degrees, pelvic tilt of 30-degrees, and sagittal vertical axis of 0-centimeters (Figure 5).

Figure 5. Pre-op scoliosis x-ray: lumbar lordosis 56-degrees, Pelvic Incidence (PI) 66-degrees, Pelvic Tilt (PT) 30-degrees, Sagittal Vertical Axis (SVA) 0-centimeters.

Diagnosis

L5-S1 degenerative disc disease with chronic refractory back pain

Selected Treatment

The patient underwent a L5-S1 anterolateral lumbar interbody fusion without any complications. Bone graft consisted of an allograft containing mesenchymal stem cells.

Post-operatively, scoliosis films are obtained to evalate global spinal balance, and the patient was immediately mobilized.

Figure 6. Post-operative x-ray demonstrates L5-S1 anterolateral lumbar interbody fusion.

Figure 7. Post-operative lateral x-ray demonstrates L5-S1 anterolateral lumbar interbody fusion.

Outcome

The patient was discharged from the hospital on post-operative day 1. At her most recent follow up, 3 months post-op, she is doing very well. Her pain is minimal and she is off of all narcotics.

The post-op scoliosis x-ray (Figure 8) shows lumbar lordosis of 63-degrees, pelvic incidence of 63-degrees, pelvic tilt of 27-degrees, and sagittal vertical axis of 0-centimeters.

Figure 8. Post-op lateral standing x-ray demonstrates LL 63-degrees, PI 63-degrees, PT 27-degrees, and SVA of 0-centimeters.

Case Discussion

Eeric Truumees, MD

Chief Executive Officer

Seton Brain and Spine Institute

Dr. Uribe and colleagues present the case of a 40-year-old female with a long history of non-operatively managed axial back pain ostensibly related to degeneration of the L5-S1 disc. Every aspect of the assessment and surgical management of axial back pain remains controversial, though, at the very least, we should remember our vow to “do no harm.” With a focus on sagittal balance, an ALIF was performed and appropriate sagittal balance obtained with an excellent, though early, clinical result. While I have partners who never operate on axial pain conditions, for me, critical factors include the type of pain, psychosocial characteristics, response to previous management, and the radiographic features detailed here.

We are not given much information about the mechanical aspects of this woman’s symptoms, but night pain requiring opioids is not a typical feature in my practice. Instead, I am looking for increased discomfort when sitting and bending forward, often relieved with recumbency.

This patient has had a host of non-operative treatments, some more reasonable than others. For example, I have not found epidurals particularly helpful in the axial pain population. I would, on the other hand, be very interested in what was done during physical therapy. In particular, what helped and what made it worse? Her facets look relatively preserved, so I am not clear on the indication for radiofrequency ablations either.

When considering surgery, however, the pain must be of sufficient chronicity and severity to justify operative intervention. This patient seems to qualify on that account. I would defer surgery until secondary gain and psychosocial distress has been addressed, but those factors are also not described here.

If the patient is considered a good candidate for a surgical intervention, the question becomes: which approach? The imaging findings become critical here. This patient’s disc degeneration is described as “severe,” though the disc height loss is, at most, moderate. Some anterior osteophyte formation is seen, but there is little fatty infiltration of the multifidus and the facets, as noted, are preserved. To me, this leaves all the options “on the table.”

I am most concerned about the sizable subchondral cyst seen in the anterior-inferior L5 vertebral body. This healthy female has a vacuum disc sign and no real risk factors for an indolent disciitis, but the night pain is concerning. At the least, this would limit my consideration of lumbar disc arthroplasty. Ultimately, a one-level ALIF, utilizing an anterolateral approach, as performed here, is a great option in healthy young females with intractable back pain. I know I am not alone in awaiting robust data delineating the benefits of grafts containing mesenchymal stem cells with predicate allograft. Dr. Uribe and colleagues appear to have achieved an excellent early result and are to be commended.