Clinical Key Points:
This patient suffered a Cauda Equina Syndrome but despite urgent treatment was left with severe & degrading symptoms said to be untreatable.
History & Prior Treatment:
Zophia developed back pain aged 11 with episodes lasting two weeks at a time, three times a year. This was treated with non-steroidal anti-inflammatory therapy and muscle relaxants. She commenced training in medicine, but at age 18 she developed left sided sciatica to the ankle with a sense of hot water passing down the back of the leg with weakness and atrophy of the calf and some lesser symptoms on the right hand side. This led to an L5/S1 decompression in 1982 aimed at treating back pain radiating around the waist and her sciatica (Ischalgia). This improved her symptoms slightly but she continued with these until she underwent an L4/5 and L5/S1 decompression and fusion with a Daab Interspinous H plate in 1982 which improved her back pain a little. This was removed in 1985 with progressive recurrence of symptoms over the next two months and the development of a high fever. This was treated with multiple antibiotics. Her symptoms persisted and she underwent an L3/4 decompression in 1990. However, she continued with symptoms particularly in the left anterior thigh and left iliac crest region. This led to a further decompression this time at L2/3 in 1992. She had persistent symptoms which were attributed to arachnoiditis in 2000.
Her sitting duration was 5 minutes & her static standing duration was 2 – 3 minutes. There was increasing weakness with walking and sphincteric dysfunction.
Distribution of symptoms
70% of her symptoms related to her back with stabbing pain around the waist radiating into the groins and anterior lower abdomen with particular pain over the left lower paravertebral muscle at its insertion into the iliac crest. She had aching centrally in both buttocks with stabbing and aching in both anterior thighs with pins and needles in this territory. She had aching and burning in the posterior thighs. She had burning in the right shin with numbness in the left calf and shin and pins and needles in the soles of both feet.
Weight bearing X-rays revealed a L4 – S1 fusion, L3/4 triangulated disc with advanced settlement into minor Retrolisthesis. L2/3 advanced degeneration with a gas sign, left lateral osteophytosis and L3/4 right lateral osteophytosis
MRI scans revealed that L5/S1 was fused. There was an osseous bridge fixing the posterior rim of L4/5 laterally on the left, L2/3 exhibited anterior epidural scarring, L3/4 exhibited circumferential epidural scarring. At L5/S1 the left exiting root was swollen and surrounded by perineural scarring.
She had a numb lateral border of the left foot with hypersensitivity in the distal L5 distribution and the left foot was swollen. The left knee jerk was absent, the left ankle jerk diminished but the power was normal.
Endoscopic Minimally Invasive Spinal Surgery: - January 2008
Left L4/5 Spinal Probing and Discography and Endoscopic Lumbar Decompression and Foraminoplasty
On probing L4/5, pain was reproduced in the back, paravertebral gutter, left buttock and posterior thigh, in the extra foraminal zone, and upon displacement of the exiting nerve. Discography revealed a minor central collection with immediate leakage from entry portal.
An Endoscopic Lumbar Decompression revealed thick perineural scarring, binding the nerve to the facet joint margin, extra foraminal muscles and inter transverse ligament, redundant disc, posterior longitudinal ligament, ossified Superior Foraminal Ligament and facet joint osteophyte.
The foramen was defined with the laser and the perineural scarring removed, the nerve was mobilised from these structures and the posterior vertebral body, the hyperaemic Posterior Longitudinal Ligament and the epidural granulation tissue.
The ascending facet joint osteophyte was removed, the foramen undercut and the Superior Foraminal Ligament removed with the powered reamer. The descending nerve was defined and mobilised and the exiting nerve liberated.
To date she has had an almost complete diminution in her back pain and in the pain in both legs and has returned to full activity.