Tagged: Leg pain after XLIF
jayd10033ParticipantMay 20, 2022 at 5:29 amPost count: 69
I have begun to feel what I believe is sciatica. Minor ache in lower right back, ache in buttock, back of leg, calf, occasionally toe. Not searing radiating pain, but some achy radiation. Uncomfortable to sit for long periods. Some relief when I cross the affected leg over the other knee when sitting in a stretch.
Could this have anything to do with my recent L3-4 fusion? I don’t usually have this issue. My surgeon said my symptoms are likely coming from L5-S1, so not really related, but curious for your take. I did take a Medrol dose pack after 2 weeks of no remittance, but it hasn’t helped. I really don’t want another MRI or surgery :)– how long should I wait before I do anything besides wait? It’s been about 4 weeks of this now.
A January (pre-fusion) MRI said the following:
At L4-5 and L5-S1, there are no disc herniations, significant disc bulge, spinal stenosis or foraminal narrowing. Stable findings.
JoshuaDonald Corenman, MD, DCModeratorMay 20, 2022 at 10:34 amPost count: 8436
Can I assume that your XLIF also had posterior stabilization (screws in the back)? How recent was your surgery and how long after the surgery did you start to notice the buttocks/leg pain?
Dr. Corenmanjayd10033ParticipantMay 20, 2022 at 11:29 amPost count: 69
Surgery 2/25. Buttock / leg ache started 3-4 weeks ago.
Below is the detail of the surgery.
INCISION AND EXPOSURE: Following the surgical time-out and radiographic localization utilizing fluoroscopy, which was interpreted intraoperatively by the surgeon, a 25-mm incision was made in a paramedian manner off of the midline and lateral to the pedicles on the left L3 and L4. Electrocautery was utilized to dissect down the lumbar fascia. Digital dissection was utilized to locate the Wiltse plane bilaterally and to palate the L2-3 and L3-4 facet joints.
INSTRUMENATION/SCREW PLACEMENT: Screws were placed utilizing the Globus ExcelsiusGPS robot according to the preoperative computerized plan. Globus headless Creo AMP screws were placed with 6.5 x 45 mm screws placed at all locations. All screws tested satisfactorily with triggered EMG testing and were visualized in both AP and Lateral planes utilizing fluoroscopy. All screws were satisfactory as interpretted intraoperatively by the attending surgeon.
ILIAC CREST BONE MARROW HARVEST: through a separate fascial incision, 5cc of cancellous bone marrow was harvested from the the left iliac crest for fusion purposes and used to impregnate Vitoss Tricalcium Phospate allograft for fusion purposes. Copious irrigation was performed and a layered closure was performed with vicryl and monocryl.
POSTERIOR SPINAL FUSION: Utilizing the retractor blades, the left L3 and L4 medial transverse processes, L3 pars, and the lateral aspect of the left L3-4 facet joint were identified. The posterolateral bony elements were denuded with electrocautery and then decorticated utilizing aggressive currettage. The space was packed with local autogenous bone graft and additional Vitoss with bone marrow aspirate in order to perform posterior spinal fusion posterolaterally at the facet.
POSTERIOR INSTRUMENTATION: A 55 mm rods was placed. Set screws were placed and then finally tightened utilizing torque-limiting screwdriver. The entire construct was then visualized utilizing fluoroscopic imaging in both AP and lateral views and noted to be in appropriate location. In this manner, posterior non-segmental instrumentation was performed.Donald Corenman, MD, DCModeratorMay 20, 2022 at 11:59 amPost count: 8436
OK, surgery was approximately 3 months ago. Buttocks ache started 1 month ago.
Your op report (only for the posterior approach) notes only left sided screw placement and no intraoperative guidance imaging (O-arm or other) but robotic guidance and electrical stimulation which was reported as normal. Since your leg pain is right sided, I am going to assume that left sided screw placement is not the cause.
What can possibly occur in some XLIFs (which are typically left sided approach) is that the spacer cage placement can occasionally push out a small herniation to the opposite side. Either that or a stretch injury to the nerve root can occur. In both scenarios however, typically the discomfort starts within a week from surgery but some delay can occur.
The proper treatment is first to give oral steroids, then if no response, new imaging would be in order.
Dr. Corenmanjayd10033ParticipantMay 20, 2022 at 12:39 pmPost count: 69
Apologies, I left out an entire operation!
INCISION AND EXPOSURE: Following surgical time-out and radiographic localization, a 4 cm incision was made in the left flank over the L3-4 disc space in a transverse manner. Electrocautery was utilized to achieve hemostasis. Blunt dissection was utilized to dissect through the subcutaneous fat. With great care in the lumbar fascia was incised with Metzenbaum scissors. The external oblique, internal oblique and transversalis musculature was spread bluntly. The transversalis fascia was snipped and the retroperitoneal space was entered. Digital dissection was utilized to develop the plane lateral to the psoas and to reflect the peritoneal sac anteriorly. Retroperitoneal fat was gently dissected. The psoas muscle was palpated.
SEQUENTIAL TUBE DILATION: Sequential tube dilation was performed with the NuVasive NeuroVision system with triggered EMG hunting algorithms and fluoroscopic guidance gently spreading the fibers of the psoas muscle and docking on the left L3-4 disc annulus. A K wire was inserted into the left L3-4 disc annulus for stabilization. The Maxcess retractor also under triggered EMG and docked on the disc. This was also performed under fluoroscopic guidance. The lateral annulus was visualized. A hand-held EMG probe was utilized to confirm that no neurologic structures were within the surgical field. Microscopic magnification and microsurgical techniques were also utilized for hemostasis and to confirm that no neurologic structures were at risk.
EXPLORATION OF LEFT LUMBAR PLEXUS: The left L3 nerve root was visualized and explored status-post discitis with extradiscal and foraminal extension resulting in radiculopathy. Neuroloysis of the left L3 nerve root and lumbar plexus was performed utilizing surgical microscopy and microsurgical techniques. At the the completion of the this portion of the procedure, the L3 nerve root and component of the lumbar plexus was free of further compression.
ANTERIOR DISCECTOMY: An annulotomy was performed in the left lateral annulus followed by discectomy with pituitary rongeurs and Kerrison rongeurs. A sharp Cobb was utilized to elevate the cartilaginous endplates were well was left to them off of the cephalad aspect of L4 and the caudad aspect of L3. The remaining cartilaginous endplates were removed. There was no gross evidence of infection in this disc. Similarly, the bone was of good quality. Ring curettes and rasps were utilized to prepare the endplates with healthy bleeding bone.BONE MARROW HARVEST: 10cc of bone marrow was harvested from S1 utilizing a Jamshidi needle and syringe for autologous fusion purposes.
ILIAC CREST BONE MARROW HARVEST: A Jamshidi needle was inserted through a separate fascial incision and separate skin incision into the left posterior superior iliac spine. 5 cc of bone marrow was aspirated in order to combine with of ethos tricalcium phosphate allograft for fusion purposes.
ANTERIOR LUMBAR INTERBODY FUSION: An appropriate-sized NuVasive titanium cage was chosen with a 55 mm x 22 mm lordotic footprint 8mm cage chosen. This was filled with a combination of local autogenous bone graft saved from the endplate shavings, allograft with bone marrow aspirate and extra small infuse. The cage was then inserted under fluoroscopic guidance. Excellent distraction and fit was noted.
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