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There are a number of unanswered questions regarding your biomechanics. A “backwards lean” (extension posturing) could be from any number of conditions. What does your standing lateral X-ray show? What is your lordotic angle measure? What does your sacral angle measure? What is your pelvic tilt angle?

What do your flexion/extension X-rays demonstrate? What is your global range of motion of the lumbar spine?

Do you have a lateral scoliogram X-ray? What is your positive or negative sagittal balance? Do you have a thoracic hyperlordosis (Scheueremann’s disorder)?

Backwards leaning can also be antalgic (holding a posture to reduce pain).

As you can see, the biomechanics of your condition is still relatively unknown according to your current understanding. You need more workup to determine what is causing the pain and the lean.

Dr. Corenman

First- please let me know the level of the herniation. Is it mid back (thoracic spine) or lower back (lumbar spine)?

Any time you have a known preexisting hernation with worsening symptoms, one of the first questions should be if the symptoms are the same but with greater intensity or are the symptoms different. The reason is due to either recurrent herniation or a hernation at a new level.

A recurrent hernation at a previously herniated level will typically intensify preexisting symptoms and a hernation at a new level will typically yield different symptoms.

In either case in my opinion, a new MRI should be considered.

Dr. Corenman

You have a condition called failed back surgery syndrome (FBSS). After your first two surgeries that I assume were decompressions, you eventually had an anterior lumbar interbody fusion (ALIF). You can read about both of these topics on the website.

The questions are if you have a solid fusion at L4-5 or L5-S1, if you have residual nerve compression of those level or some form of permanent nerve injury. The answers to those questions can be determined from a new CT scan, a new MRI, X-rays including flexion and extension films and a thorough physical examination.

If you want to come to the office, I cannot prescribe these studies beforehand. However, I can have all those studies obtained the day you come to the office. Please call my office and talk to one of my nurses for further information.

Dr. Corenman

I think you are on the right track. Flexion/extension X-rays are important to determine the weight bearing component of your disorder. A CT myelogram is a great test to determine both fusion quality and nerve compression. If you were my patient, that would be a test I would endorse.

In addition, as I mentioned before, a SNRB of the L2-3 level bilaterally would be considered if there was a solid fusion of L3-S1. A good temporary result would indicate those nerve roots as the pain generator (see pain diary on the website). This does not necessarily mean that the nerves are mechanically compressed but the likelihood of that is very high.

If the L2-3 level turned out to be the problem, surgery would depend upon the angulation of the deformity. If the endplates of the two vertebra were parallel on standing films but there was instability (spondylolisthesis) present, a simple one level TLIF fusion would be the likely surgery needed. If there was significant angulation (called a kyphosis), adding another level might be necessary to correct the deformity.

Dr. Corenman