History :
On Examination of Spine :
While walking, the patient was leaning or tilting to one side. When he tried to bend forward or backward, he experienced severe pain. A healed scar from his previous surgery was also visible. Additionally, when asked to bend forward, he was unable to touch his feet.
Previous Surgery (1989):
The patient underwent surgery for his lower back (lumbar spine) back in 1989. Unfortunately, this surgery did not provide any relief from his pain. This means that despite undergoing a medical procedure to address his back issues, his condition did not improve as expected.
Increasing Pain Over Time: :
Instead of getting better, the patient’s pain has actually gotten worse over the years. This is indicated by the phrase “His pain had significantly increased in the last few years and was gradually increasing day by day.” It suggests that his pain has been progressively worsening, impacting his quality of life more and more as time goes on.
Nature of Pain:
The patient experiences various types of pain
Lower back pain:
This is pain located in the lower part of the back, likely stemming from the lumbar region. Lower leg pain: Pain that extends down into his legs, possibly indicating nerve compression or irritation affecting the legs.
Neck pain:
Besides the lower back and legs, he also experiences pain in his neck, suggesting that his spinal issues may be affecting multiple areas of his spine.
Impact on Daily Life:
The pain affects many aspects of the patient’s daily life
Sleep disturbance:
The pain disrupts his sleep, likely causing discomfort and making it challenging for him to get restful sleep.
Difficulty in bed turning:
Turning in bed has become difficult due to the pain, which can severely impact his ability to find a comfortable sleeping position.
Difficulty in daily activities:
The pain interferes with his ability to perform everyday tasks, making simple activities more challenging and painful.
Loss of Hope and Reluctance for Second Surgery:
The failed first surgery has led the patient to lose hope in finding relief through surgical means. He is hesitant and reluctant to undergo a second surgery due to the negative experience and lack of improvement from the initial procedure. This reluctance is understandable given his past disappointment and the apprehension associated with undergoing another surgery.
Recent Symptoms:
In addition to his chronic pain, the patient has experienced new symptoms in the last month.
Difficulty passing motion:
This may indicate bowel or digestive issues that could be related to his spinal condition or could be a separate concern.Difficulty passing urine: Similarly, difficulty in urination may point to potential nerve compression or dysfunction affecting urinary function, which can be a serious symptom requiring medical attention. Overall, the patient’s situation is complex, involving chronic pain, past surgical disappointment, reluctance for further surgery, and new symptoms that need thorough evaluation and management.
MRI :
Radiological Investigation:
There is a defect in the spine at levels L3-L5 due to a previous surgery involving laminectomy (removal of parts of the spine bones). The patient also has left lumbar scoliosis, which is a curvature in the lower back, likely caused by the old surgery. The curvature is centered around LV3 with the concavity (curving inward) towards the right side. Additionally, there is compression of the spinal vertebra LV3 when viewed from the front (AP compression of LV3)
1.[Post-operative status]:
This refers to the patient’s condition after surgery.
2.[Disc degeneration and disc bulge at L2/3 level]:
The discs between the vertebrae at the L2/3 level have worn down and are bulging out. This is accompanied by enlargement of joints in the spine (facetal hypertrophy) and thickening of a ligament in the spine (ligamentum flavum), causing moderate narrowing of the canal where the spinal cord passes through (canal stenosis)
This means that the spaces adjacent to the spine and the openings through which nerve roots exit the spine are narrowed, leading to compression of nerves at the L3 level.
3.[Disc degeneration and disc bulge at L3/4 level]:
Similar degenerative changes are observed at the L3/4 level, causing severe canal stenosis and compression of nerves at the L4 level.
4.[Narrowing of lateral recesses and neural foramina with compression of bilateral traversing L4 nerve roots]:
Again, the spaces next to the spine and the openings for nerve roots are narrowed, resulting in compression of nerves at the L4 level.
5.[Disc degeneration and disc bulge at L4/5 level]:
At this level, there’s disc degeneration and bulge along with enlargement of joints, leading to narrowing of the spaces next to the spine (lateral recesses). The disc is also pressing against the nerve roots that branch out from the spinal cord (traversing nerve roots).
6.[Narrowing of the neural foramina]:
The openings through which nerve roots exit the spine are narrowed at this level.
7.In simpler terms, the patient has post-surgery spinal degeneration with disc bulges, joint enlargement, ligament thickening, and narrowing of spaces and openings next to the spine. These changes are causing compression of nerve roots at multiple levels, contributing to potential pain and discomfort.
Operation :
On September 1st, 2023, the patient underwent a surgery to relieve pressure on the nerves in the lower spine (L3 to L5) and to stabilize the spine. The surgery was done while the patient was asleep under general anesthesia. It involved opening up the spine from the back (posterior) to remove tissue pressing on the nerves (decompression and laminectomy). Additionally, the surgery included fusing the bones in the lower back together using rods and screws (posterior lateral fusion) and a procedure called transforaminal lumbar interbody fusion (TLIF) and fixation specifically at the L4-L5 level. This surgery was done to address issues and stabilize the spine
OPERATING SURGEON:Dr Sangram Rajale
IMPLANTS : JAYON
-Monolock Ultra polyaxial screw = 6.5x45mm -4 used
-Monolock Ultra polyaxial screw = 5.5x45mm -1 used
-Posfuse TLIF Cage =8mmx25mm-1 used
Condition On Discharge :
a. The patient was doing well after the surgery and was moved to a regular hospital room.
b. The patient didn’t need intensive care after the surgery.
c. On the second day after surgery, we helped the patient sit up in bed.
d. By the third day after surgery, the patient was able to walk outside and climb stairs.
e. Right after the surgery, the patient felt a lot better with their leg and back pain. We checked their X-rays and saw that their spine alignment was significantly improved.
f. The patient went home on the fourth day after surgery and came back after 15 days to have the stitches removed.
g. A month later, the patient reported feeling 95 to 98% better, regretting not having the surgery sooner and enduring pain for so long.
Q and A :
Revision lumbar spine surgery refers to a surgical procedure performed on the lower region of the spine (lumbar area) after a previous surgery has already been done in that area. It is typically performed to address persistent or recurrent symptoms, correct complications from the initial surgery, or treat new issues that have developed since the first surgery.
Revision lumbar spine surgery can be challenging due to several factors:
- Scar Tissue: After the initial surgery, scar tissue can form, making it harder to access and navigate the affected structures.
- Altered Anatomy: Previous surgeries can change the normal anatomy, making it more challenging to identify and work with the structures during revision surgery.
- Weakened Bone: Previous surgeries or conditions like osteoporosis can weaken the bone, increasing the risk of complications such as fractures during revision surgery.
- Nerve Damage: Revision surgeries pose a risk of nerve damage, leading to neurological deficits like weakness, numbness, or pain.
- Infection Risk: The presence of scar tissue and altered tissue integrity increases the risk of infections during revision surgery.
- Implant Issues: If implants were used in the initial surgery, their removal or adjustment during revision surgery can be challenging and may result in complications.
Potential complications include:
- Nerve Injury: Damage to nerves can cause sensory or motor deficits, including pain, numbness, weakness, or paralysis.
- Infection: Surgical site infections can occur, requiring antibiotics and additional interventions.
- Bleeding: Excessive bleeding during or after surgery can lead to complications and may require blood transfusions.
- Dural Tears: Tears in the dura (membrane covering the spinal cord) can result in cerebrospinal fluid leaks and increase infection risk.
- Implant-related Complications: Issues with hardware like screws or plates, such as migration or breakage, can occur.
- Failed Fusion: If spinal fusion was performed, there’s a risk of non-union or pseudoarthrosis, requiring further surgeries.
- Persistent or Worsened Symptoms: Some patients may experience ongoing or exacerbated symptoms despite surgical intervention.
Patients should have thorough discussions with their healthcare providers, understand the potential risks and benefits, and undergo careful preoperative evaluation and planning. Revision surgery requires expertise from the surgical team due to its complexity and potential challenges.