Clinical Key Points
This patient suffered with disabling Back Pain for over 20 years. and a misleading MRI scan.
History & Prior Treatment
Kathryn first started with back problems aged 23. She underwent Osteopathy and physiotherapy but without benefit. Flare ups would take six weeks to two months to settle.
In August 2000 she had a discectomy for a sequestrated disc at L4/5. This cured the tingling in her foot and sciatica but did not ameliorate the back pain.
In December 09 she slipped on the back steps outside her house, since then the pain has been severe.
At presentation to the Spinal Foundation in February 2010, Kathryn was finding it difficult to work because the pain so intruded upon her concentration. She was unable to sit for longer than 5 minutes in a soft chair and 5 – 20 minutes in a hard chair. Her walking duration was 5 – 20 minutes on both the flat and even ground. Walking used to help. She used to walk 8 miles but in pain followed by an activity penalty the next day but this remedy no longer worked despite Physiotherapy and Osteopathy and Epidural Injections and extensive pain modification therapeutic programme.
Distribution of symptoms
95% of her pain symptoms resided in her back and in both buttocks.
Investigations
Weight bearing X-rays revealed facet joint osteophytes and retrolisthesis at L5/S1. The L4/5 disc was significantly reduced in height & exhibited posterior osteophytes and overriding facet joints.
MRI scans in 1997 revealed a L5/S1 disc protrusion with a radial tear & left paracentral sequestration with reaction around the nerve. Dehydration at L4/5 and L5/S1. In 2010 there was perineural scarring at L4/5 and a radial tear in the disc & Left lateral recess stenosis. At the L5/S1 protrusion had resorbed.
Endoscopic Minimally Invasive Spinal Surgery: March 2010
Right L4/5 and L5/S1 Spinal Probing and Discography, L4/5 – Endoscopic Lumbar Decompression and Foraminoplasty & a L5/S1 – Therapeutic Discogram
On probing L5/S1 the interval and annulus produced low level intensity back pain but thought to be too high in the back. Discography revealed multi loculated degeneration. The disc accepted 2 mls of dye and was treated with a Therapeutic Discogram.
On probing L4/5, the interval reproduced has back pain, her spasm/jolting pain, buttock and groin pain. Full AP and lateral degeneration was noted together with a right paracentral leak spreading down to L5/S1 foramen and causing pain.
Endoscopic Lumbar Decompression and Foraminoplasty revealed extensive hypervascular thick scar in a large foramen with a degenerate disc. The nerve was densely adherent to the Superior Foraminal Ligament, facet joint capsule, apical osteophyte, inferior pedicle, and vertebral body shoulder osteophyte.
The scarring was removed, the facet joint undercut with the trephines, after definition of the structures by laser ablation. This resulted in removal of the impinging apical osteophyte & provided access to the epidural space. A positive fat sign was produced with rather fibrotic post operative epidural fat. A Vertebral shoulder osteophyte was chamfered. The nerve root was liberated from the ganglion to the inferior pedicle.
Outcome:
She is delighted that her back pain has been resolved and that she had only a minor postoperative flare. She returned to work at 6 weeks and is completing her Muscle Balance Physiotherapy rehabilitation programme.