Spinal column pathology
Short Summary

39-year-old male suffers of back pain since 1994. In 2006, following recurrent back pain, investigated by MRI that showed advanced degenerative abnormalities, inversion of physiological lordosis (apex at L1-L2), and L4-L5 discopathy. EMG disclosed slight radiculopathy at L5 and the lumbar MRI showed left mediolateral D10-D11 disc protrusion causing medullary distress. There was also left L4-L5 disc herniation. The patient had MRI scans and radiograms that disclosed flattening of the cervical lordosis, thoraco-lumbar kyphosis and degenerative changes at different levels. Laminectomy surgery was recommended.

Patient's Questions
1)            Do you agree with the suggested therapy?If so, what are the risks of relapse and/or complications?
2)            Are there any effective alternative nonsurgical therapies?
3)            What is the expected prognosis?

4)            Are there any centers of excellence in Italy?
Medical Background

Sex: M, Age: 39 years
Diagnosis: Spinal column pathology.
Case history:
In 1994, the patient experienced intense low back pain after lifting weights at work. The symptoms resolved without further problems.
The patient works as a docker at a port, but has not lifted heavy loads for two years (he is currently an operations manager).
In 2006, the patient experienced low back pain. A lumbar MRI was performed, which showed very advanced arthrosic abnormalities, inversion of physiological lordosis with a fulcrum at L1-L2, discs D12-L1, L1-L2 and L2-L3 were barely represented, L4-L5 discopathy, disc L5-S1 appears well hydrated, somatic posterior osteophytosis at all levels, in particular at D12-L1, L1-L2, L2-L3 and L3-L4 with abruptions in liquor space.
Since February 2007, onset of pain radiating to the anterior surface of both thighs.
EMG (05/2007):Slight radicular neurogenic pain at L5 on left.In addition to known findings, the lumbar MRI performed on 04/2007 showed left mediolateral D10-D11 osteodiscal protrusion causing medullary distress, slipped (herniated) disc, probably left mediolateral L4-L5.
During a recent specialist vertebral-medullary surgical visit, the physical examination showed the following:“gait with no pathological characteristics, perhaps a little stiff although tandem gait was effective, as well as on tips of toes and heels; non-painful cervico-dorso-lumbar rachis; no sensitivity abnormalities, no segmentary strength abnormalities, no unevenness in the Mingazzini maneuver; osteotendinous reflexes:Active tricipital and bicipital reflexes, very active rotular reflexes, achilles reflexes tending to exhaustible clonus, Babinski:big toe tending to dorsiflexion bilaterally; negative Lasegue and Valsala.There is a significant discrepancy between the radiological and clinical picture.”
Therefore, the patient was advised to have a cervical, dorsal and lumbosacral MRI, as well as an x-ray of the cervical, dorsal and lumbosacral rachis, the significant results of which are shown below:
-       Cervico-dorso-lumbar MRI of 02/2008 à
o   In the cervical area, as far as can be evaluated due to motion artefacts, there is a tendency to rectification of physiological lordosis.Very slight spondylotic abnormalities with slight retrosomatic osteophytosis at C3 posterial-inferior edge. No evidence of significant herniated discs.The wideness of the vertebral canal is reduced primarily on a congenital basis.

o   In the dorsal area, the wideness of the vertebral canal is reduced in the region D9-D12, both on a congenital and acquired basis by multiple disc protrusions and initial hypertrophy of yellow ligaments on a degenerative basis.The vertebral bodies in the inferior dorsal region are also slightly reduced in height.At D8-D9 and D9-D10, posterior disc protrusions can be observed.At D10-D11 there is an herniated disc that impacts the ventral surface of the medulla; this produces a hyperintense signal at T2, as in spondylogenic myelopathy, which is substantially unchanged compared with the previous MRI performed on 04/2007.

o   In the lumbosacral area, compared with the previous MRI, the inversion of the physiological lordosis appears less accentuated with a fulcrum at L1-L2.The reduced height of L1 and slight wedge deformation of the anterior trunk are substantially unchanged.The osteochondral abnormalities of facing bounding soma at L2-L3 and the known diffuse spondylotic abnormalities are unchanged.As far as it is possible to assess in the saggital region, the multiple disc protrusions in the area D12-L5, where the intersomatic discs appear reduced in height and dehydrated, remain unchanged.

-       X-ray of cervico-dorso-lumbar rachis performed on 02/2008 à
o   In cervical region:rachis in line with a tendency to inversion of lordosis.Slight abnormalities with spondylosis of vertebral bodies.Initial osteophytosic protrusion in the right conjugate foramen between C4-C5. The remaining conjugate foramina are within normal limits.Disc spaces are substantially preserved.

o   In the dorso-lumbosacral region: rachis in line, with preserved dorsal kyphosis and straightening of lumbar lordosis. In the dorsal region, signs of osteophytosic spondylosis that are more accentuated in the lower half of the dorsal region of the rachis and in the area of the lumbar metamers, especially in the top half. The dorsal metamers in the bottom half, from D7 to D12, appear reduced in height, as is also the case for the L1-L2 bodies. Disc spaces are also reduced in the dorsolumbar passage region, especially between L1-L2 and to a lesser extent between L2-L3. Interapophysary arthrosic signs in inferior lumbar region.
During the specialist visit on 03/2008, the above results were reviewed and the following was underlined:
- MRI:Multisegmentary stenosis of the spinal canal at all levels; in particular, marked stenosis in the passage D10-D11 where there is compression and slight abnormality in the medullary signal, also slight narrowing of the passage D9-D10; signs in the dura also at C3-C4, C4-C5 and C5-C6; multiple osteodiscal protrusions in the lumbar region.
 - X-ray: cervical rachis à inversion of physiological lordosis with a fulcrum at C3-C4; dorsal rachis à straightening of physiological kyphosis; lumbar rachis à straightening of physiological lordosis, deformation of L1 soma.
During this visit, and based on the above results, the specialist proposed a D9 and D10 laminectomy surgery to be performed following the patient's decision.

Expert's Opinion

The patient's main problem is D10-11 disc herniation with cord compression, both clinical and radiological. I agree that decompression is needed and better sooner than later. The cord compression results from central and slightly left disc herniation. The thoracic cord should never be mobilized or retracted, therefore decompression by simple laminectomy does not seem suitable in this case. Furthermore, laminectomy in abnormal kyphotic region may further de-stabilize the spine, leading to progression of the deformity.  My opinion is that D 10 corpectomy (Lt approach) with D9-11 fusion may give better results and lower the risk of iatrogenic neurological deterioration. Alternative procedure may be wide laminectomy with excision of Lt D11 pedicle, enabling decompression without touching and retracting the cord. Posterior fusion is needed in those cases. Third option may by minimal invasive (endoscopic) removal of the disc. It is needless to mention the importance of spinal cord monitoring in such surgeries.
As to the alternative ways of therapy, the fact that there are already signs of upper motor neuron impairment makes surgery to be the preferable treatment.
As to the prognosis, we usually state that in cord compression (thoracic, cervical), decompression is done to stop further deterioration but improvement is often noted. Fusion should reduce the pain originating in the fused segment only. The fact that the patient has many degenerative discs that are not going to be fused leave the back pain as unsolved issue. One may suggest including the upper lumbar spine in the fusion area with correction of the segmental kyphosis in the region. This may be done but the surgeon should consider the fact that the kyphotic segment may probably be rigid and the fusion is about to end in a degenerative level (exerting extra load over an unhealthy mobile segment).
As to your question about Italian centers of excellence, in a few cases I co-operated with Proph. S. Boriani (Hospital Majora, Bologna) and he seems as a very experienced spinal surgeon.