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Single level disc disease with back pain


Introduction

Low back pain is one of the leading causes of emergency visits in the United States, leading to billions of dollars in loss of productivity each year. Most Americans will experience back pain during their lifetime, and a majority of these are self-limiting and never require additional treatment. Others may improve with conservative management such as nonsteroidal antiinflammatory drugs and physical therapy, while others may need additional treatment. The exact mechanism leading to back pain is unclear, although the degenerative process is thought to play a role in many cases requiring advanced treatment. Diagnostic evaluation for back pain without any red flags (i.e., fever, weight loss, weakness, bowel/bladder incontinence, numbness) should be started after attempted conservative management if the symptoms do not abate. The diagnostic imaging should include magnetic resonance imaging (MRI) and flexion-extension x-rays. Additional imaging studies may be required to determine the cause of the back pain in some cases. The diagnosis is made after the exclusion of radicular pain, spinal deformity, instability, and neural tension signs. It should be noted that there are also nonanatomical causes of pain that should also be considered when determining the cause of axial back pain (i.e., depression).

Example Case

  • Chief complaint: lower back pain

  • History of present illness: A 43-year-old female with a history lumbosacral back pain after working out. She has worsening pain with activity, which is improved by rest. This includes prolonged sitting, lifting, and repetitive motions. She has done physical therapy, injections, and ablations with minimal improvement. Imaging was done and there was concern for lumbar disc disease ( Figs. 15.1–15.3 ).

    Fig. 15.1, Preoperative magnetic resonance images. (A) T2 sagittal and (B) T2 axial images demonstrating disc degeneration at L5-S1.

    Fig. 15.2, Preoperative computed tomography discogram. (A) Sagittal, (B) axial at L4-5, and (C) axial at L5-S1 images demonstrating normal nuclear morphology at L4-5 but with advanced degenerative disc degeneration with full-thickness posterior annular fissure and filling of a broad-based posterior disc protrusion at L5-S1.

    Fig. 15.3, Preoperative x-rays. (A) Flexion and (B) extension x-rays demonstrating no dynamic instability with normal range of movement of the lumbar spine.

  • Medications: spironolactone, trazodone, ibuprofen, acetaminophen

  • Allergies: no known drug allergies

  • Past medical and surgical history: none

  • Family history: noncontributory

  • Social history: teacher, no smoking history, occasional alcohol

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/biceps/triceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis; 2+ in bilateral patella/ankle; no clonus or Babinski; no Hoffman; sensation is intact

  • Mohamad Bydon, MD

  • Neurosurgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Frank M. Phillips, MD

  • Orthopaedic Surgery

  • Rush University

  • Chicago, Illinois, United States

  • Alugolu Rajesh, MD

  • Neurosurgery

  • Nizam’s Institute of Medical Sciences

  • Punjagutta, Hyderbad, India

  • Yasuaki Tokuhashi, MD

  • Orthopaedic Surgery

  • Nihon University

  • Oyaguchi Kamicho, Itabashi-ku, Tokyo, Japan

Preoperative
Additional Tests Requested Pain rehabilitation evaluation None

  • Straight leg test

  • F18 bone scan

  • Anesthesiology evaluation

  • Discogram

  • Disc injection

  • Psychological testing

Surgical Approach selected Conservative management. However, if worsening and surgical approach becomes necessary, L5-S1 TLIF Would advise against surgery because of unpredictable outcomes, but, if pursued, L5-S1 ALIF Left L5-S1 discectomy and foraminotomy

  • L4-5 positive: L4-5 OLIF with percutaneous pedicle screws

  • L5-S1 positive: microendoscopic discectomy

Goal of Surgery Decompression and Stabilization Stabilize spine Decompression of neural elements

  • L4-5 positive: spinal stability

  • L5-S1 positive: decrease intradiscal pressure

Perioperative
Positioning Prone Supine Prone

  • L4-5 positive: right decubitus, then prone on Hall frame

  • L5-S1 positive: prone on Hall frame

Surgical Equipment Fluoroscopy Intraoperative Neuromonitoring (SSEPs)

  • Fluoroscopy

  • Vascular repair instrument on standby

  • Fluoroscopy

  • IOM (SSEP)

  • Fluoroscopy

  • Microendoscopic discectomy system

Medications None None None None
Anatomical considerations Nerve roots, dura, musculature, bony structures Great vessels, sympathetic plexus in males Dura, nerve roots Bone/muscle/neural structures, major vessels, ureter
Complications feared with approach chosen Incidental durotomy, nerve root injury, wrong level surgery, vascular injury Vascular injury Durotomy, nerve root injury Wrong level surgery, neurological injury
Intraoperative
Anesthesia General General General General
Exposure L5-S1 L5-S1 L5-S1

  • L4-5 positive: L4-5

  • L5-S1 positive: L5-S1

Levels decompressed L5-S1 L5-S1 L5-S1

  • L4-5 positive: L4-5

  • L5-S1 positive: None

Levels fused L5-S1 L5-S1 None

  • L4-5 positive: L4-5

  • L5-S1 positive: None

Surgical Narrative Prone position, localize appropriate level using fluoroscopy, create 2-3 cm incision immediately lateral to pedicle of L5-S1, perform exposure and visualization using a Jamshidi needle and Kirschner guide wire, insert tubular retractor and endoscope, perform L5-S1 laminectomy with facetectomy, remove ligamentum flavum with curved microcurette, perform micro discectomy and prepare endplates, perform trial of interbody cage as appropriate (to restore appropriate lumbar lordosis, anterior third to maximize lordosis), place percutaneous pedicle screws and rod, standard closure Position supine, x-ray to guide incision to L5-S1 disc, anterior retroperitoneal approach, mobilize and retract great vessels, bipolar cautery dissection only over anterior spine, identify midline, thorough wide discectomy back to PLL, good end plate preparation, size ALIF cage ensuring good fit with appropriate lordosis and posterior disc space distraction, cage and screw placement, layered closure Position prone, place trunk on bolsters to create flexion at L5-S1, identify L5-S1, midline skin incision, subperiosteal dissection of paraspinal muscles on left side preserving tissue around facets, cut ligamentum flavum and detach from lower border of L5, left L5-S1 foraminotomy performed with undercutting facet, retract root medially and identify disc space, incise disc space sharply, complete disc decompression, pull loose fragments out, layered wound closure

  • L4-5 positive: stage 1 for L4-5 OLIF, right lateral decubitus position, check level with fluoroscopy and mark L4-5 vertebral body, 5–7 cm incision at 6 cm anterior vertebral marking, dissect abdominal muscles and expose retroperitoneal exposure, retract psoas to expose L4-5 disc, curettage disc, insertion of lateral lumbar interbody cage with graft bone, closure with drain; stage 2 for percutaneous screws, position prone, mark L4 and L5 pedicles under fluoroscopy, 3 cm longitudinal incision and 2 cm transverse incision on the pedicles, L4-5 pedicle screw insertion under fluoroscopy, rod insertion, fix with compression force between screws L5-S1

  • positive: position prone, 2 cm incision on L5-S1 interlaminar space under fluoroscopy, insert 16 mm tubular retractor and endoscope, resect yellow ligament and L5-S1 herniotomy, standard closure with drain

Complication Avoidance Minimally invasive approach, proper anatomical structure identification to avoid injury Bipolar cautery dissection only over anterior spine, make sure to identify midline, ensure posterior disc space distraction to provide indirect foraminal decompression, pay attention to great vessels during cage and screw placement Position to promote flexing at L5-S1, left-sided exposure with preservation of facets, foraminotomy on left side

  • L4-5 positive: two-stage with percutaneous screws, pedicle screws under fluoroscopy, compress on screws

  • L5-S1 positive: minimally invasive, endoscope, no bone removal

Postoperative
Admission Floor Floor Floor Floor
Postoperative complications feared Durotomy, Nerve root injury, CSF leak Vascular injury Weakness, nerve root injury, CSF leak, discitis

  • L4-5 positive: injury to intestines, ureter, or vasculature

  • L5-S1 positive: CSF leak

Anticipated length of stay Outpatient or 1 day Outpatient or 1 day 1 day

  • L4-5 positive: 1–2 weeks

  • L5-S1 positive: 2–3 days

Follow up testing Spine XRs in 6 weeks, 6 months, 12 months, 24 months L-spine x-rays 6 weeks, 3 months, 6 months, 1 year after surgery None

  • L4-5 positive: CT 7 days, 3 months after surgery

  • L5-S1 positive: lumbar x-rays after surgery

  • MRI: 1–3 months after surgery

Bracing None None None

  • L4-5 positive: soft brace for 3–6 months

  • L5-S1 positive: no bracing or possible 1 month soft brace

Follow up visits 2 weeks, 6 weeks, then as needed 2 weeks, 6 weeks, 3 months, 6 months, 1 year after surgery 7 days, 4 weeks after surgery 4 weeks after discharge
ALIF , Anterior lumbar interbody fusion; IOM , intraoperative monitoring; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; OLIF , oblique lateral interbody fusion; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potential.

Differential diagnosis

  • ▪

    Disc degeneration

  • ▪

    Discitis

  • ▪

    Osteomyelitis

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