Case Study: Lumbar Nerve Root Compression

This case involved a 19 year-old male patient who had a history of low back pain for about a year and was reporting severe, constant, and aching lower back pain of 8-9 on a scale of 10, as well as radicular right leg pain, decreased sensation on the right, difficulty straightening his right leg making it difficult to walk. An MRI showed a rather large L5-S1 herniated disc on the right side with severe degenerative disc disease.

The defendant performed an L5-S1 decompression with posterior lumbar interbody fusion and placement of a TraXis cage. Infuse and autograft were used to complete the interbody fusion. Intraoperatively, the defendant found that the patient had severe degenerative disc disease with a large right paracentral disc herniation, with the disc acting like a broad-based disc bulge with some components of hard and soft disc. There were no significant sequestered or extruded fragments however.

Postoperatively, the patient initially reported an improvement in his leg pain and less discomfort in his lower back. Within a month however, he was complaining of significant ongoing pain and was also displaying significant narcotic seeking behavior. The defendant began tapering the patient’s narcotics and prescribed him physical therapy. The patient continued to complain of rather significant lower back pain however. A diagnostic x-ray showed that the grafts and hardware were in good position, although a CT myelogram done three months later did show some ectopic bone formation in the spinal canal in the area of the diskectomy, but the nerve root appeared to be above the level of the bony spur. The patient continued to complain of back pain and diagnostic studies continued to show no evidence of disc herniation or nerve root impingement and an EMG showed normal sensory nerve conduction.

The first goal of the defense visual strategy was to allow the jury to see the normal anatomy of the lumbosacral nerve roots and to show how they exit the foramen at L5-S1. This could then be used in conjunction with a second board for comparison against the plaintiff’s preoperative and postoperative anatomy, in order to show how his nerve roots exited at that level before and after the defendant’s procedure. These exhibits were designed for side-by-side use in order to clearly show that preoperatively the plaintiff’s S1 nerve root was compressed by his bulging L5-S1 disc; the L5 nerve root was not directly compressed. Postoperatively however, both the S1 and L5 nerve roots were decompressed and remained so, unaffected by the ectopic bone growth in the spinal canal, with the L5 nerve root exiting above the growth and the S1 nerve root exiting below the growth. Color-coding of the L4 and L5 nerve roots helped to focus the jury’s attention on the path of these 2 pairs of nerves.

Lumbosacral Nerve Roots

Lumbosacral Nerve Roots 2

The next exhibit went in to further detail to show the preoperative condition of the plaintiff’s lumbosacral spine, showing his large disc herniation and severe degenerative disc disease, as well as the postoperative condition of the plaintiff’s lumbosacral spine, showing the decompression and benign ectopic bone growth.

Preoperative Lumbosacral

Post-operative Lumbosacral

Next, the defense visual strategy tackled the development of the ectopic bone growth in the plaintiff’s spinal canal. This exhibit first showed the plaintiff’s initial post-operative condition, showing the placement of Pro Osteon, BMP sponge, Bone autograft, and the TraXis cage with BMP sponge in order to show that at the conclusion of the procedure, there was no graft material in the spinal canal and neither the L5 nor the S1 nerve roots were compressed. An overlay showed that by several months after the procedure, the ectopic bone growth was extruding into the spinal canal, but it was below and above the L5 and S1 nerve roots, respectively, and not compressing either root.

Preoperative condition

Preoperative condition overlay

Lastly, in order to reinforce the defense contention that the post-operative condition showed no impingement on either the L5 or the S1 nerve roots on the right, the next exhibit showed the jury the pre-operative films compared to the post-operative films, using overlays to explain what is seen on these films.

Post-op Films

Post-op Films

The visual exhibits created for this case served to simplify and clearly outline the defense’s case in the setting of complex anatomy, pathology, and surgical technique, and were instrumental in obtaining a defense verdict.

—Editorial contributed by Emily Ullo Steigler, MS, CMI
—Illustrations contributed by Robert Edwards, MS, CMI

5 Comments

  1. Gaby - June 26, 2013

    Is there any additional information about the patient’s history and any additional tests done on him?

  2. Gaby - June 26, 2013

    Post-op symptoms, aggravating and alleviating factors, when pain is triggered, etc. Sorry, forgot to specify I was referring to post-op pain. Any weight-bearing MRI ordered by defendant?

    • seif - June 27, 2013

      This patient had no significant medical history besides a motor vehicle accident and a work injury. Since he had no physical deficits besides his pain, the only preoperative testing was the MRI, which was ordered after PT failed to provide any significant relief. As mentioned in the original blog post, the plaintiff initially reported good results postoperatively. When he did begin to complain of pain, he reported low back pain with right leg pain, although on average, he described the pain as better than preoperatively. He reported no alleviating factors to his discomfort but did report that it was aggravated with prolonged sitting or standing. His physical exam revealed that he could forward flex to below knee level and the straight leg raise was no longer uncomfortable on either side. Within several months, there was no longer radiation of pain into his right leg, his strength and deep tendon reflexes were intact, and he had no trouble walking. The plaintiff established care with a new provider about six months after his procedure and that doctor did order an MRI about a year after the initial surgery, although that MRI was not a weight-bearing MRI. Of note, the MRI showed no evidence of disc herniation or nerve root impingement.

  3. Tina Miller - December 31, 2013

    this is excellent!

  4. SLynn - July 8, 2014

    I have had more surgeries of my cervical, thoracic and lumbar spine than I have in fingers and toes! I have failed back surgery. As years go by I always improved. I was in an attorney’s office one time and it got uncomfortable. I need doctors to take care of me. My post op scans were always good but pain continued. These risks are clearly explained and you sign that paper. Because I need doctors to take care of me I would never sue. Medicine is a “practicing” field of work. Doctors are not gods.

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