Spinal pathology

Spinal pathology – additional opinion
Short Summary

75-year-old male with multiple complaints related to both his lumbar and cervical spine. He complains of low back pain, cramping and numbness in his thigh muscles, radiating left leg pain to his toes, as well as unsteady gait. He experiences numbness in his shoulders, arms and hands that gets worse over the day. He had a C4-5 fusion and a lumbar procedure at L4-5. The cervical MTI showed degenerative disease worse at C6-7 where there is moderate central and foraminal stenosis. The lumbar MRI showed loss of normal lumbar lordosis with multilevel degenerative changes worse at L3-4 where there is moderate to severe stenosis.

Patient's Questions

1. In accordance with the consultant’s request, I am sending you my EMG results, in order that you can refer to them, in relation to the surgery.

2. Will it be possible, when undergoing the surgery on L3-L4, to also treat L4-L5, or only L5?

3. Is it possible to treat my neck using physiotherapy, despite the fusion of my cervical vertebrae that I had ten years ago?

4. Will it be possible to undergo the surgery on L3-L4 using THESSYS method, with local anesthesia, and using endoscopic procedures, and not open surgery?
 

Medical Background

Current illness :
Consultation Results by an orthopaedic surgeon:
Tests carried out on 02/2009,
Lower back and right hip pain for the past 8 months
Pain does not radiate to legs.
Pain remains when patient is at rest
Fusion of C4-5, 10 years ago.
Fusion of L4-5 from 02/08
Complained of difficulty in walking and instability 08/08.

Findings
Lasègue's sign negative, no pathological neurological findings [No spasticity, clonus, etc]
Pulses were felt
Large joints – no pathological findings
Lumbar spinal x-ray – severe degeneration at L4-5
Bone Scan showed high absorption D12 and L1 on RHS
CT showed osteophytes in the area of absorption
Imaging – union +++
Imaging – updated union +++
Cervical CT shows no evidence of gross pressure on spinal cord
02/09 negative Lasègue's sign. Strength 5/5, sensation =
Reflexes – knees very active, heels active.
Pulse no pathological findings, joints no pathological findings

MRI 12//08: Constriction of C2-3 and C6-7, with no signs of myelopathy.

Lumbar MRI complete union of L4-5, limited narrowing of L3-4

EMG root damage L4-5-S1?

Diagnosis
Low Back Pain
Osteoporosis

Treatment and Recommendations
The option to widen the canal at L3-4 was explained to the patient
No prognosis of improvement of spasticity and unstable gait.

Review and Follow-Up
Follow up: As needed

MRI Results:
Performed on 12//2008

Cervical Spine MRI
Vertebrae C1-D4
The MRI was carried out with FSE T2 weighting, and SE T1 weighting, before and after Gadolinium injection. Images were taken in sagittal, axial and coronal sections.

Results
Union of vertebral bodies C4 and C5
Vertebral canal is normal diameter
Craniocervical passage within normal limits
C1-2: Within normal limits
C2-3 Protrusion of central disc causing indentation of anterior spinal cord
C3-4: Slight diffuse protrusion of disc causing constriction of anterior dural sac
C4-5: Union of vertebral bodies after fusion surgery. Disc is not visible at this level. Bilateral constriction of neural foramina.
C5-6: Bilateral constriction of neural foramina, more pronounced on the right, due to hypertrophy of intervertebral joints.
C6-7: Medium to severe diffuse protrusion of disc, causing pressure and distortion of spinal cord, including bilateral narrowing of the foramina.
C7-D1: Implicit spondylolisthesis of C7 on D1, with no evidence of significant protrusion of intervertebral disc.

Spinal cord thickness, course and signs normal. No evidence of myelopathic abnormalities of the cord.

Lumbar Spinal MRI
Vertebra D10 to S2
The MRI was carried out with FSE T2 weighting, and SE T1 weighting, before and after Gadolinium injection. Images were taken in sagittal, axial and coronal sections.

Results
The vertebral structure is within normal limits.
Vertebral canal is normal diameter.
D12-L1: Within normal limits.
L1-L2: Minimally diffuse protruding disc, no evidence of pressure on the nerve roots. Schmorl’s nodes protrude inferiorly.
L2-3: Moderately to greatly diffuse protruding disc. Severe constriction of dural sac is caused by diffuse protrusion of disc and hypertrophy of ligamenta flava.
L3-4: Significant constriction of dural sac due to greatly diffuse protrusion of disc and hypertrophy of ligamenta flava.
L4-5: Erosion of intervertebral disc. Moderately diffuse protrusion of disc and hypertrophy of ligamenta flava causing constriction of dural sac.
L5-S1: Within normal limits.
Terminal end of conus medullaris defined as normal.

EMG
Nerve Conduction Results: Right Peroneal, conduction normal, F-wave latency normal
Left Peroneal, conduction normal, F-wave latency normal
Right tibial, conduction normal, F-wave latency normal
Left (sacral?) conduction normal.

Needle Exam Results: Vastus Med: Right – No spontaneous activity, full recruitment, broad units.
Left – No spontaneous activity, full recruitment, broad units
Tibialis Ant: Right – No spontaneous activity, full recruitment, broad units
Left – No spontaneous activity, full recruitment, broad units
Gastroc Med: Right – No spontaneous activity, broad units
Left – No spontaneous activity, broad units
Paraspinal muscles not checked due to surgical scarring in the test area


Summary The neurophysiological picture is consistent with nerve root damage at a number of levels, at least L4, L5, S1 bilaterally, with no signs of active denervation.

Patient’s complaints:
Lumbar Spine
1. Unstable gait. I need to consciously think about each and every step I take. Otherwise, I am liable to fall.
2. I am only able to walk about thirty meters before my back and leg muscles tire.
3. I can only stand for about five minutes before I must sit.
4. I suffer significant pains along the entire width of my lower back. These pains interfere with my daily routine.
5. I suffer shooting pains in my left leg, all the way to my toes, as well as cramping in my thigh muscles.
6. My quadricep muscles are partially numb

Cervical Spine
1. Around five months ago, my arms and shoulders started to feel numb throughout the day. This worsens when I sleep.
2. I am suffering from reduced feeling in my fingertips

Expert's Opinion

1. In accordance with the consultant’s request, I am sending you my EMG results, in order that you can refer to them, in relation to the surgery.

2. Will it be possible, when undergoing the surgery on L3-L4, to also treat L4-L5, or only L5?

Yes all the levels could be addressed through the same surgery.

3. Is it possible to treat my neck using physiotherapy, despite the fusion of my cervical vertebrae that I had ten years ago?

Yes you can have physical therapy after a spinal fusion. In addition, the EMG results were of your lumbar spine (evidence of lower lumbosacral nerve involvement but to acute/active changes) , an upper extremity EMG would also be helpful.

4. Will it be possible to undergo the surgery on L3-L4 using THESSYS method, with local anesthesia, and using endoscopic procedures, and not open surgery?

My understanding is that the Thessys system is used primarily for disc herniations. While minimally invasive techniques can be used for lumbar laminectomy they are generally not done under local anesthesia alone.

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