Elective Revision Surgery Restores Quality of Life Following Prior Failed Surgeries

Unusual Indication for Carotid Stenting Over Endarterectomy
May 2, 2022
Treatment of Spondylolisthesis and Disc Herniation
May 13, 2022

Fig 1. Preoperative MRI demonstrating severe degenerative disk disease at L4-5 and L5-S1, as well as an extruded disk fragment at L5-S1 causing the patient’s right leg sciatica

Fig 2. Preoperative CT scan demonstrating significant disk space collapse and bony sclerosis at L4-5, accounting for the patient’s overall axial lower back pain.

A 60 year old male otherwise fit and healthy sales manager with history of three prior microdiscectomies (L4-S1) presented to NSPC with complaints of persistent back pain and constantly recurring right lower leg pain with radiation down the back of his thigh into his heel. He had attempted multiple rounds of physical therapy and epidural steroid injections with no lasting pain relief. His past surgical history was significant for bilateral total hip replacements, and notably his right hip arthroplasty had failed twice and had required extensive revision surgery. He was very understandably frustrated, did not wish to be on long-term pain medications and was not interested in spinal cord stimulator treatment until all other potential surgical options had been exhausted.

Radiographic workup demonstrated a fourth recurrent disk herniation at L5-S1 as well as overall loss of the normal curvature of his lumbar spine (‘flatback syndrome’), very likely due to the significant disk degeneration caused by his repeated prior surgeries as well as his inability to compensate for this via pelvic movement due to his bilateral hip replacements. Rather than simply performing another discectomy, the decision was made to fuse both the degenerated segments of his lumbar spine via minimally invasive techniques. This was meant to definitively correct the patient’s global spinal alignment issues and to completely eliminate the chance of another painful disk herniation.


Fig 4. Postoperative X-rays with placement of titanium grafts and screws from L4-S1. Note the restoration of lordosis (natural spinal curvature) with the expandable grafts

Fig 3. Preoperative X-rays, again demonstrating loss of normal lumbar curvature at the two lowest spinal levels. Note the bilateral hip replacements limiting patient ability to compensate

During surgery two large titanium grafts were placed following total removal of both disks (including the recurrent herniated disk fragment). Both grafts were designed towards restoring natural lumbar spine curvature, and percutaneous pedicle screws were placed during the surgery as well to ensure 360 degree stabilization and to optimize bony fusion. Despite the fact that this was the patient’s fourth spinal surgery with extensive associated scar tissue, due to the minimally invasive techniques used he did not suffer a spinal fluid leak and his blood loss was minimal. He was discharged from the hospital after a 72 hour stay. At 6 months postoperatively he was exercising 4 times a week, and at one year out he is pain free and off of all pain control medications, both narcotic and non-narcotic.

Fig. 5 Pre- and postop CT scans of the lumbar spine, for comparison

This surgery demonstrates the importance of having a fellowship trained spine surgeon versed in both minimally invasive and open spine surgical techniques evaluating a complex spine case that has failed numerous prior surgeries. Frequently issues of global spinal alignment need to be taken into account and addressed, instead of focusing on one level of the spine alone.





Elective Revision Surgery Restores Quality of Life Following Prior Failed Surgeries

To learn more about the author, click his name or photo:


To learn more about the author, click his name or photo: