Back Pain & Long Standing Disc Extrusion
Clinical Key Points:
This patient suffered with increasingly severe back pain for a decade resulting from a conservatively treated extruded disc protrusion.
History & Prior Treatment:
When presenting to the Spinal Foundation in 1999 he had a left L5/S1 protrusion and right foraminal collection at L4/5. He was averse to surgical intervention. These symptoms initially treated by Physiotherapy, Chiropractic Therapy, Root Blocks, Facet Joint injections have been worsening to the extent that he had to stop football a year ago. Previously he had sharp pains in the lumbosacral junction lasting for seconds but in 2009, the duration of this pain at each event had increased on each occasion. During a flare of symptoms he suffers with such stabbing pain every 30 minutes. The flares may last for 2 weeks and were recurring every 2 to 3 weeks and his sitting , static standing and walking durations were less than 5 minutes.
Distribution of symptoms
His pain manikin reveals aching and stabbing at the lumbosacral junction radiating out into both paravertebral gutters without radiation to the buttocks or legs.
Investigations
Weight bearing X-rays revealed a spasmodic right tilt at L3/4. L5/S1 evidenced a left intradiscal tilt on a balanced Sacrum, at L4/5 a 30% loss in disc height & L5/S1 is small. The pedicles at L3, L4 and L5 were very short. He had facet joint osteophytosis impinging into the foramen at L4/5 and L5/S1.
MRI scans performed in February 2009 revealed a High Intensity Zones at L4/5 & lateral recess stenosis at L5/S1 more marked on the left. The right L5/S1 foramen evidenced marked fibrosis with superior displacement of the nerve. To a lesser extent similar changes were noted on the left-hand side.
His scan in 2007 had evidenced a large left L5/S1 extrusion into the left foramen which subsequently resolved leaving extensive fibrosis behind as a consequence of the persisting irritation from the extruded disc material.
He has absent ankle jerks and sensation is reduced in the left L5 and S1 distributions particularly in the left calf.
Endoscopic Minimally Invasive Spinal Surgery: - November 2009
Right L4/5 and L5/S1 Spinal Probing and Discography,L4/5 – Laser Disc Decompression & L5/S1 – Endoscopic Lumbar Decompression and Foraminoplasty.
On probing L4/5 the anterior facet joint margin and annulus produced back pain on the right. Discography revealed a hamburgershaped enlarged nucleus pulposus with a left foraminal slow leak.
This level was treated with a Laser Disc Decompression using 800 joules 20/20. Depomedrone and Gentamycin were instilled after washout.
On probing L5/S1the anterior facet joint margin produced right sided back pain more intensely. Gas in the disc, facet joint hypertrophy, a parrot peak osteophyte and a large vertebral rim osteophyte were found.
This level was treated with an Endoscopic Lumbar Decompression and Foraminoplasty. After defining the facet joint rim with the laser, the parrot beak osteophyte was removed and the facet joint was undercut to gain epidural access. The Safe Working Zone and epidural space was filled with grey stained scar. The vertebral body rim osteophyte was very prominent. The nerve was cleared of thick scar and the Superior Foraminal Ligament was removed. The nerve was mobilised from the smooth vertebral osteophyte and cleared of scaring down to the inferior pedicle. Endoscopic Intradiscal Discectomy was not required.
Outcome:
He had a post operative flare during weeks 3 & 4 following surgery but thereafter the back pain disappeared and he returned to work at week 5. He is not taking any medication following cessation of the flare. The very occasional ache in his foot resolved during his post-operative Muscle Balance Physiotherapy. He remains pain free.