Revision Spine Surgery Case 1

Case Review #1: 27 year old female presents with foot drop after 3rd lumbar surgeries from Robert Pashman

A 27 year old female presented status post three microdiscectomies. The patient had a sudden onset of foot drop. Dr. Pashman performed a posterior spinal fusion on the patient.

  1. Case Review: 27 year old status-post three microdiscectomies, presented with foot drop. Treated with an anterior and posterior spinal fusionRobert S Pashman, MDScoliosis and Spinal Deformity Surgerywww.eSpine.com
  2. Patient History• 27 year old female from Washington• Disk herniations at both L4-5 and L5-S1. The patient decided that despite some weakness, she wanted to have a child in advance of any spine surgery. Ultimately, her symptoms resolved.• She become re-symptomatic subsequently and had two microdiscectomies.• The second disk herniation resulted in severe weakness and foot drop in both the L5 and S1 distributions of the left leg. It was associated with severe pain. Microdiscectomy Surgery was performed on an emergent basis in Washington.• The weakness did not resolve after the third microdiscetomy.
  3. Patient History – cont.• The patient, at this point, has significant low back pain and also has plantar flexion and extensor hallicis longus and tibialis anterior weakness of the left leg. She has associated calf atrophy also on the left hand side and walks with a discernible limp that actually accentuates her foot drop with increased cadence. She had negative straight leg raising and a well-healed incision posteriorly.• A combination of MRIs and CT myelogram show that the patient has evidence of microdiskectomy at L4-5, L5- S1 and still has some blunting of the myelographic stripe at L5-S1 and L4-5 in the lateral recess.
  4. Pre-op X-raysShe also has a disk bulge at L3-4, whichcomplicates the situation, because ultimately totake all the pressure off the nerve, the patient isgoing to need reconstruction and fusion. But,since she has a disk bulge at L3-4, I talked toher extensively about it, and my feeling is thatshe will have anterior reconstruction at L4-5and L5-S1 #1 to recreate normal lumbarlordosis, but also has an augmentation forposterior cemented fusion, which has adecreased chance of having healing because ofthe previous posterior surgery. Because L3- 4 isan adjacent segment and has a disk bulge, wewill instrument her posteriorly from L3 to S1,use laminectomy bone for the posterior lateraland transverse fusion.
  5. Indications for Surgery• Status post microdiskectomy, L4-5, L5-S1 x3.• Severe motor sensory deficits, left leg, due to residual compression lumbar spine.• Lumbar kyphosis.• Degenerative disk disease, L4-5, L5-S1.• Failed conservative therapy.
  6. Surgical Strategy – Stage 1• Abdominal retroperitoneal approach to the lumbosacral spine.• Radical diskectomy, L5-S1, L4-5.• Anterior interbody fusion with PEEK device, L4-5, L5-S1, measuring 8 and 8 mm, respectively.• Anterior interbody fusion bone graft with RH bone morphogenic protein in the central PEEK spacer, L4-5, L5-S1.• Segmental spinal instrumentation L4-S1 using 5.5 stainless steel rod construct.• Posterolateral intertransverse fusion L4 to S1 using locally harvested laminectomy bone.
  7. Surgical Strategy – Stage 2• Re-exploration decompression under the microscope with complete laminectomy, L5, and subtotal laminectomy L4.• Intralaminar laminectomy and facetectomy re-exploration decompression, lateral recess decompression and neuroforaminotomy L4-L5, L5-S1 bilaterally.• Intralaminar laminectomy, facetectomy, lateral recess release L3- L4 for lateral recess stenosis.• Intraoperative SSEPs.• Intraoperative fluoroscopy.
  8. Post-Op Films
  9. Pre-Op/Post-op ComparisonThe patient returned to Washington approximately 10 days followingsurgery. She wore a brace and returned to teaching a few weeks later.She has regained strength and control of her leg and is very happywith her outcome.
  10. 2 year follow-upA year after surgery, the patient got pregnant. She sent us abirth announcement with a note stating that she had no backpain during her pregnancy or delivery.