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  • NSpine
    Participant
    Post count: 13

    Dear Dr Corenman

    40 year old male with a 5 year history of lower back issues that has included 2 microdiscectomy operations in 2016 at the L4/L5 level.
    Recently been to see a spine surgeon with the following taken from MRI:

    L4/L5 grade 5 degenerative disc with modic changes noted on the right side associated with disc bulge and osteophytes bilaterally with some facet joint arthritis and hypertrophy more on the right causing some lateral recess stenosis and touching of the L5 root bilaterally and also possible dynamic element of the foraminal stenosis on the right side. there is also evidence of L4/5 decompression on the right side with possible scar tissue around the nerve root

    L5/S1 grade 4 degenerative disc with central disc bulge with asymmetrical fact joint hypertrophy causing some lateral recess stenosis more on the right

    The specialist has started with booking in transforaminal steroid injections at both levels and on both sides which I have agreed.

    He said end treatment is likely two level fusion.

    Do you have any thoughts on this as I would like to avoid any more surgery but after 4 decent years, the issues in my legs are becoming a big issue.

    Thanks again for all the valued input on this forum

    Best regards

    NSpine

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    At L5-S1, modic changes are an indication of the failure of the disc to absorb shock causing impact-type pain. Asymmetric facet degeneration might indicate angular collapse of the vertebra. If symptomatic, both issues would need to be addressed by a fusion. You have had two prior L4-5 decompressions with continued root compression at this level (“lateral recess stenosis and touching of the L5 root bilaterally and also possible dynamic element of the foraminal stenosis on the right”). This level also has angular collapse features.

    Do you have more back pain or do you have buttocks leg pain with standing that fades with sitting or flexing forward?

    Dr. Corenman

    NSpine
    Participant
    Post count: 13

    Many thanks for the reply.

    Leg pain is the dominant issue, with standing being the worst and sitting or lying down the best.

    Back pain is present in flexion and extension with a heavy stiff feeling and inflexibility.

    What method of fusion would you potentially think most appropriate?

    Thanks again.

    NSpine
    Participant
    Post count: 13

    Hello Dr Corenman

    Would you advise PLIF, TLIF, Alif or XLIF?

    Thanks

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    The L%-S1 levels can be approached from the front or the back (ALIF or TLIF) but the ALIF needs to be supported by posterior hardware which needs of course a posterior approach meaning an ALIF is really a front and back fusion. A TLIF is a front and back approach only through the back (one incision) and the approach also allows individual nerve root decompression at the same time.

    XLIFs are also good but the procedure does need a posterior instrumentation like an ALIF does. XLIFs generally cannot be performed at L5-S1 “cleanly”.

    Dr. Corenman

    NSpine
    Participant
    Post count: 13

    The surgeon has indicated a two level fusion TLIF – Is this procedure one that you do regularly?

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