Case Study: Debilitating Lower Back Pain
Dr. Peter Hollis
The patient is a generally healthy, alert 79-year-old female with a four-year history of debilitating lower back pain for which physical therapy has provided no relief. In 2010 she underwent a failed micro lumbar discectomy at another hospital, after which she developed progressively worsening radiating pain in both legs. An epidural steroid injection six months after surgery also brought no improvement. In October 2011 she came to North Shore-LIJ’s Cushing Neuroscience Institute for a surgical consult, bringing a recent MRI of her lumbosacral spine. We identified severe spinal stenosis and spondylolisthesis with degenerative scoliosis localized at L3-4 and L4-5. After discussions with the patient and family members we recommended a multilevel bilateral decompressive laminectomy, medial facetectomy and foraminotomy in conjunction with insertion of fixation hardware and intertransverse autologous bone graft to supplement spinal fusion.
The surgery, performed in November 2011, began with the patient placed on her side and under general anesthesia. After being wired for lower extremity EMG and somatosensory-evoked potential monitoring, the first phase of surgery began with discectomies in the L3-4 and L4-5 disk spaces. Once the damaged disks were removed they were replaced with PEEK interbody prostheses. Each prosthesis was precisely sized according to the interbody space available and filled with Osteofil bone matrix to enhance grafting. The prostheses were then tamped into place under interoperative AP and lateral C-arm (fluoroscopy) guidance, with excellent reductions in the patient’s degenerative scoliosis and subluxation obtained. Throughout continuous intraoperative EMG stimulation using the Neurovision retractor/dilator system provided safe percutaneous passage through the surrounding tissues of the spine and to the spinal nerve roots.
During the next phase the patient was placed on her stomach and a small posterior midline incision made over L3 to L5 with the goal of decompressing associated nerves and preparing the way for a fixation device to stabilize the spine at this location. The spinous processes of L3 and L4 were removed after which a bilateral decompressive laminectomy was carried out. A high-speed drill was then used to drill down through facet-transverse processes bilaterally at L3, L4 and L5. (On the right side, where the patient’s primary pain symptoms were found, the dura was found to be eroded into a cellophane-thin layer in several places due to chronic wear. These were sutured closed.)
Lastly, the six holes previously drilled were probed for stability and holding capacity, titanium screws inserted, and custom-bent titanium fixation rods inserted to create a permanent internal brace or cage. Bony material harvested from the laminectomy were prepared in a bone mill and used to complete an autologous bone graft between the transverse processes.