Pain and weakness treated by Discectomy

History:The patient was a 37-year-old carpenter who had a chief complaint of severe, persistent left leg pains. The patient felt that his pain developed after lifting a heavy object at work and that over time his symptons were aggravating with repeated work activity. The symptoms started as a backache with some left buttock pain that then progressed to severe pain all the way down to the toes. At times this felt like electric shocks with tingling. Over the past 3 weeks the patient also noted some weakness in the left foot. Despite rest, medication, and pain modalities symptoms were progressive and interfered with all activities of daily living including sleep.

Physical Examination:The patient was an athletic appearing young man, walking with a slowed gait. No significant tenderness in the paraspinal muscles of the lumbar back region was noted. Lower extremity examination revealed full and painless hip motion and a positive straight leg raise on the left at 60 degrees (with patient flat, slowly raising the leg provoked significant leg pains shooting down from the buttock area). Weakness was noted in the toe extensors of the left foot as well as the ankle dorsiflexors (these muscles are innervated by the L4 and L5 nerve roots). Numbness was noted on the dorsum and lateral aspect of the foot and ankle. The Achilles tendon reflex on the left side was absent (this reflex passes through the S1 nerve root).

Radiographic Evaluation:Radiographs of the lumbar spine revealed some straightening of the lumbar lordosis but no evidence of fracture or significant spinal malalignment (figure 1). An MRI revealed a large extruded disc fragment (a type of disc herniation that involves a fragment of disc separated from the rest of the disc and that is lodged in the spinal canal) located at the L5-S1 level and compressing the nerve roots (figures 2,3,4).

Treatment Options: Depending upon the size, location and associated symptoms or nerve dysfunction a number of treatment options are available for herniated discs. In this case, the patient had developed weakness, progressive worsening pain despite medication, rest and pain modalities. Remaining options to consider include: continued analgesics, physical therapy, epidural injections and surgery.

Discussion:In general terms, disc herniations that do not lead to marked canal narrowing or neurologic dysfunction do not require surgical treatment. In this particular case the patient had seen no relief with non-operative care. Epidural steroids are an option in some cases particularly when nerve irritation and no significant compression are noted. In this case a large extruded disc fragment was identified in the spinal canal and weakness in the leg had developed. A surgical option was discussed with the patient who wished to pursue this route due to the severe nature of the pain and failed response to other non-operative approaches. The risks and potential benefits of surgery were reviewed in detail with the patient, as was the long-term risk of re-herniation, instability and possible need for another intervention at some time.

Treatment Results:As planned, a posterior lumbar decompression and discectomy were performed with complete freeing up of the spinal canal and nerves at the L5-S1 level. The patient noted marked reduction in his pain post-operatively. Upon hospital discharge the patient took only over the counter medication for several more days. The foot weakness resolved completely over the weeks following surgery and the patient returned to work.