L3-5 Lumbar instrumented fusion

BACKGROUND

Osteoarthritis is a degenerative disease which causes pain, swelling and reduced motion of joints. It occurs when the cartilage between bone surfaces wears away resulting in contact between the bare surfaces of the bone. Risk factors include increasing age, family history, menopause (in women), joint injury and obesity. In the spine, facet joints are especially vulnerable due to the high level of mobility and load forces they encounter (especially in the lumbar region)(1). Osteoarthritis of the lumbar spine remains a common cause of chronic low back pain (2) for which there are multiple treatment options but due to the fact that pain perception is multifactorial, management can sometimes be difficult.

CASE PRESENTATION

A 75 year old female presented with a history of chronic back pain which was not relieved by analgesia, physiotherapy and CT guided nerve block. The pain was increasingly severe and radiated to her legs. She had no other symptoms but did have a pacemaker and suffered from depression.

INVESTIGATIONS

Whilst seen in clinic, the patient had several radiographs of her back to assess her suitability for operative intervention. X-rays and CT revealed degeneration of the lumbar vertebral bodies consistent with osteoarthritis. There was obvious scoliosis (figure C), narrowing of the L3/4 disc space (figure D) and degeneration of the facet joints (especially L3/4 and L4/5).

TREAMENT

The patient was pre-assessed as an outpatient and had operative intervention. The operation was done prone using a midline skin incision called the Wiltse approach. The procedure involved insertion of right sided pedicle screws then a distracter was used to maintain the disc height whilst the other side was being prepared (figure A). Facet joints were excised from L3/L4 and L4/L5 lumbar bodies on the right side. Left sided facet joints were then excised. Finally, pedicle screws and rods were inserted to promote lumbar spine fusion. To finish the procedure a washout was done followed by closure of the fascia and skin. After the surgery, 2 doses of intravenous antibiotics were given to reduce the risk of infection.

OUTCOME AND FOLLOW-UP

Post operatively the patient readily mobilised and was deemed fit for discharge by the surgeons and physiotherapists. She went home on analgesia and physiotherapy exercises with a routine follow up appointment in 6 weeks. However, she returned a few days later with pain again and initially was non compliant with the advice of the pain team. She was discharged with long term gabapentin, amytriptilline and oramorph (for breakthrough pain). Her GP was instructed to refer her to the pain clinic if she had further pain and an appointment with the orthopaedic surgeons was remade.

REFERENCES

  1. Kalichman L, Hunter DJ. Lumber facet joint osteoarthritis: a review. Semin Arthritis Rheum. 2007 Oct; 37(2):69-80.
  2. Borenstein D. Does osteoarthritis of the lumbar spine cause chronic low backpain? Curr Rheumatol Rep. 2004 Feb;6(1):14-9.
  3. www.lowback-pain.com/surgery.lumbdecompfusion.htm

 


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