Clinical Key Points
This patient had widespread degeneration of her lumbar spine, considerable degradation of life style by pain and a high risk from surgery due a clotting disease.
History & Prior Treatment
In June 2009 Jane presented to the Spinal Foundation. She had developed back and sciatic pains in 1998 which had progressively worsened over the last 10 years. In addition she had an arthritic right knee and walked with a stick. Her abnormal gait and posture has caused her to develop a right trochanteric bursitis over the prior 5 months. She had had a right knee arthroscopy in April 2008 after which she developed two deep venous thromboses. She also suffered with secondary postural interscapular and cervical pain.
She described her lumbar symptoms as ”Fireworks” in her back with aching in both buttocks, lancinating pain in both groins and shins and paraesthesiae in the toes of both feet.
This had been treated by physiotherapy, acupuncture, chiropractic therapy, osteopathy and epidural injections to little or no avail.
Her symptoms impaired work, walking, DIY, housework, playing with the kids, gardening, driving, sporting activities. She could not sit long enough to enjoy her hobby of building dolls houses. Her sitting duration was less than 5 minutes, static standing duration 5 – 20 minutes and a walking duration of 20 – 30 minutes.
She was found to suffer with Factor 5 Leiden Deficiency and a significant propensity to thrombosis & embolism.
Distribution of symptoms
85% of her pain lodged in her back and left buttock, groin & trochanteric region.
Investigations
Weight bearing X-rays revealed diminished disc height and limited movement in extension and flexion at L5/S1. The foramen at this level was very small with a parrot beak osteophyte. At L3/4 the disc was grossly settled with small posterior vertebral rim osteophytes. This level was immobile. The vertebral rim osteophytes extended laterally bilaterally. At L4/5 she ha some anterior Olisthesis but she scuttled at this level during extension.
Her MRI Scan revealed a right extra foraminal bulge and osteophytes at L4/5. On the left there was a small foramen with osteophytosis and the nerve was displaced superiorly in the foramen. At L5/S1, the S1 nerve roots were swollen. At L4/5 on the left side there was a sharp vertebral body osteophyte distorting the nerve root pathway on the left hand side.
Endoscopic Minimally Invasive Spinal Surgery: - October 2009
Left L5/S1 and L4/5 Spinal Probing and Discography &L5/S1 – Endoscopic Lumbar Decompression and Foraminoplasty.
On probing left L4/5, the anterior facet joint margin was pain free, the interval produced mild pain and medial buttock pain. Discography produced pain in her back, left paravertebral gutter and stomach pain. Posterior two thirds degeneration was noted together with a right anterolateral collection. The disc accepted 4 mls.
When probed, the L5/S1 facet joint disc interval produced paracentral and media buttock pain and spasm. I was unable to enter the settled disc. A Radiculogram reproduced pain in the back and in the leg.
Endoscopic Lumbar Decompression and Foraminoplasty revealed a very flattened, medialised and reddened nerve root with an impinging facet joint apical osteophyte and a thick Superior Foraminal Ligament. The thick ligaments were binding the nerve to a redundant disc and facet joint margin. The facet joint and osteophyte were reamed and undercut to gain access to the epidural space. The Superior Foraminal Ligament was resected and the nerve mobilised from the Superior Foraminal Ligament, disc wall and inferior pedicle. Pain was reproduced in the groin, buttock and leg to toes during manipulation of the nerve. Haemostasis was achieved using the laser.
Outcome
She had a “high” post operatively for about two weeks but found that the Emflex anti-inflammatory therapy made her feel depressed. 6 weeks following the intervention she was pleased with the result and feels that she is 80% alleviated of her pain.
At that time she had episodes of pins and needles in the toes with numbness lasting thirty minutes four times a week. She also had occasional burning shooting pain on the right side of her spine irregularly and lasting just a few moments.
She has noticed some aching in the muscles of her lower back and shoulders but was moving more freely and no longer had the “fireworks” in her spine, buttock, groin and shin pain.
Currently she is pain free following 3 months of Muscle Balance Physiotherapy rehabilitation and has avoided a recurrence of venous thrombosis.