Lateral Recess Stenosis

 

Clinical Key Points

A patient with significant lower leg pain aggravated by activity due to Lateral Recess Stenosis.

History & Prior Treatment

Jill first had back pain about ten years ago and developed left buttock and leg pain in June 2008. She underwent conservative therapy including chiropractic treatment, acupuncture and physiotherapy with little benefit. Her pain began to worsen after heavy digging in February, by June 2008 she was in constant pain and unable to sleep. The symptoms improved somewhat but unfortunately she lifted another heavy object and since then the symptoms have not improved at all and require extensive combined medication.

Her pain was aggravated by getting out of a chair & her static standing duration was 10 minutes and her walking duration 20 minutes or half a mile. Restart time is 30 minutes and her post activity penalty is several days.

She had a calf venous thrombosis aged 28, a pulmonary embolus aged 45 & a TIA in 2000.

Distribution of symptoms

She suffered with mild aching at the lumbosacral junction. Her predominant pain (60%) was from the left mid buttock down the posterolateral thigh and calf to the left lateral malleolus where it was associated with a sharp stabbing sensation - described as a knife being thrust into the ankle.

Investigations

Weight bearing X-rays revealed Disc height is significantly reduced at L3/4 and L4/5 by approximately 80% and a right concave degenerative scoliosis.

MRI scan revealed At L3/4 there was a left extra foraminal protrusion containing a high intensity zone and at L4/5 on the left side there was lateral recess stenosis with a disc protrusion.

She had no neurological deficit.

Endoscopic Minimally Invasive Spinal Surgery: March 2009

Left L4/5 Spinal Probing and Discography, Endoscopic Lumbar Decompression, Endoscopic Intradiscal Discectomy, Neurolysis and Undercutting.

When the left L4/5 foramen was probed this proved to be pain free, however Discography at 2 mls reproduced pain in the back, buttock, calf and left and right ankle. Full AP and lateral degeneration was noted with a right and left foraminal collections.

The procedure started with Endoscopic Intradiscal Discectomy, as access did not cause neural pain, using 3 mm portal with 5 mm instruments, 3.5 gms of blue stained disc was removed. 550 J Annuloplasty was also performed.

Endoscopic Lumbar Decompression and Foraminoplasty revealed the nerve tethered to the disc and inferior pedicle.

  • The nerve was liberated from the disc and inferior pedicle
  • The Superior Foraminal Ligament was split
  • Undercutting and enlargement of the foramen was continued until access to the epidural space was achieved and the nerve had been decompressed along it length.

Outcome

She had an excellent outcome from her Endoscopic Lumbar Decompression and Foraminoplasty. She no longer uses her stick She can now sleep on her back and has returned to full activities.