Clinical Key Points
This patient suffered with “slipped disc” symptoms for over 30 years and a misleading MRI scan.
History & Prior Treatment
Geoffrey suffered with back pain since the early 1970s He suffered with attacks of right sided sciatica in the 1990s but had been able to work until he fell on 6 June, 2005.
After the fall and with a demanding physical job, his right sided sciatica persisted. Over the last 2 years he began noting symptoms developing in the left foot.
In 2008, he underwent a left arthroscopic Meniscectomy but despite this still suffered with pain in the left knee & consequently an abnormal gait. He had undergone Physiotherapy. Acupuncture. Epidural injections. Facet joint injections. One injection eased his pain for some 5 weeks. He had explored a comprehensive range of pain modifying medication.
On presentation to at the Spinal Foundation, his sitting, static standing and walking durations were less than 5 minutes.
Distribution of symptoms
His pain manikin revealed aching and burning at the lumbosacral junction with aching in both buttocks occasional stabbing pain in the right groin, aching along the lateral border of the right thigh with numbness affecting the lateral border of the right shin and extending into the dorsum of the right foot. He had aching in the right shin and pins and needles in the dorsum of the right foot and left first web space.
Investigations
Weight bearing X-rays revealed that he had a left intradiscal tilt at L4/5 and L5/S1 & a right concave thoracolumbar scoliosis with right lateral osteophytosis. He had a left sacral tilt and a slightly short left leg. He had short pedicles at L3, L4 and L5 & jack-knifes at L4/5 during extension.
MRI scans revealed a broad based disc bulge at L2/3 whilst at L3/4 there was a broad based disc bulge which was more prominent to the left of the midline. At L4/5 there was a moderate/large central disc protrusion which indented the anterior theca, but causing no exiting root compromise.
He had numbness on the sole of the right foot and over the right calf and over a patch of the right anterolateral shin.
Endoscopic Minimally Invasive Spinal Surgery: June 2009
Right L3/4 Spinal Probing and Discography, Endoscopic Lumbar Decompression and Foraminoplasty.
At L3/4 pain in the back and buttock was reproduced upon insertion of the dilator into the foramen.
Endoscopic Lumbar Decompression and Foraminoplasty revealed a nerve displaced posteriorly by lateral osteophytes in the presence of short pedicles and a small foraminal volume. The nerve was adherent to the disc, Superior Foraminal Ligament, overgrown facet joints and facet joint osteophytes. He had engorged vessels and thick scarring in the Safe Working Zone. The facet joint margin was defined and trephined producing good access to the epidural space and hyperaemic dura. The nerve was liberated from the disc, inferior pedicle and Superior Foraminal Ligament.
Outcome
He had a post operative flare following a trip but immediately after surgery he was able to turn over in bed. His sitting duration was unlimited & static standing duration exceeded 30 minutes. At 6 weeks his walking duration was a quarter of a mile or ten minutes without problems. He still had an activity penalty but in the form of muscle ache. He was pleased that the back, groin & leg symptoms have been resolved.