Sciatica, Back pain & Multiple Sclerosis & Failed Back Surgery

 

Clinical Key Points

A patient with disabling back pain and leg weakness, Failed Back Surgery, Failed Chronic Pain Management and Multiple Sclerosis.

History & Prior Treatment

Philip was diagnosed with multiple sclerosis in 1996 following an episode of optic neuritis for which he has recently undergone stem cell technology and reports a benefit.

He fell off a ladder in 2000 and developed an increase in the back pain which he had suffered since 1994 and the bilateral leg pain which he had suffered since 1996. The aggravation led him to undergo an L4/5 open decompression in 2001 which eased the parasthesiae in his thighs. In the light of ongoing and worsening symptoms he underwent a further decompression at L3/4 in 2003 without material benefit. Consequently he was referred for pain management without benefit. He underwent an MRI scan in 2006 to assess his ongoing back pain and was referred back to Mr Wilson Macdonald (Oxford) who informed him that nothing further could be done to ease his symptoms.

Distribution of symptoms

70% of his problem was aching at the lumbosacral junction with additional stabbing pain in both buttocks, burning and weakness in the adductor region of both thighs and calves. Static standing durations 10 minutes & a walking distance of 25 yards with crutches.

Investigations

Weight bearing X-rays revealed L5/S1 disc degeneration, settlement and consolidation with short pedicles and significant facet joint hypertrophy. At L3/4 there is disc height reduction with facet joint overriding and exposure of the facet joints.

MRI scans revealed evidence of previous decompressions at L3/4 and L4/5 with some epidural fibrosis at these levels but no evidence of nerve root compression. At L5/S1 there was a prominent disc bulge narrowing the right lateral recess.

Proprioception was diminished on the right, Great Toe power was reduced to grade 4.5/5.

Endoscopic Minimally Invasive Spinal Surgery: February 2009

Right L5/S1 Spinal Probing and Discography and Endoscopic Lumbar Decompression and Foraminoplasty revealed a thick calcified Superior Foraminal Ligament impacting unyieldingly on to the nerve and Dorsal Root Ganglion. The anterior margin of the facet joint evidenced overgrowth of the facet joint, a thick capsule and thick adhesions between the capsule and the nerve and the disc. The nerve was medially displaced, flattened surrounded by engorged paraneural veins, red & swollen& adherent to the facet joint and disc. An apical facet joint osteophyte was defined and found to be impinging upon the nerve. Young scar tissue was noted around the exiting L5 nerve and anterior to S1 nerve. The nerve was being pincered between the hypertrophic ridged facet joint, apical osteophyte, the Superior Foraminal Ligament, and the redundant displaced disc and tethered distally to the inferior pedicle. The disc wall was degenerate and inflamed and hypervascular in the foraminal zone.

Through the endoscope, the scarring and granulation tissue was removed using laser ablation and the nerve was mobilised from the distorted disc, facet joint and superior foraminal ligament and inferior pedicle using manual and laser ablation in the aware state.

The foramen was enlarged and undercut with the laser. The dura was mobilised and the axilla of the exiting nerve explored. The granulation and scarring were removed from the nerve root and ganglion allowing correction of the medial displacement of the nerve. The nerve was mobilised from the disc, superior foraminal ligament, facet joint and inferior pedicle until a positive fat mobility sign was produced indicating good decompression and restoration of freedom of movement to the nerve. The apical facet joint osteophyte was resected. The granulation, perineural entrapment, fibrotic tissue and superior foraminal ligament were removed with liberation of the nerve.

Outcome

At review 6 weeks following the procedure there was complete resolution of his back and buttock pain and sciatica. This outcome has survived his falls occasioned by his MS. The power in his right leg was gradually improving globally. This improvement was sustained and increasing at review 3 & 6 months later