Extensive nonoperative treatment with therapy and epidural steroid injections have failed to provide any relief of her symptoms.
What would be the most appropriate next step in treatment?
She can walk for about 3 minutes before the pain becomes unbearable.
It is relieved only when she sits down or bends forward.
Combination of these findings are compatible with discitis / osteomyelitis at L3-L4 with a prevertebral soft tissue collection, involvement of the epidural space along the left laminotomy site dorsal aspect of L3-L4, and an enhancing intradural abscess extending from L2-L3 to the sacrum. There is a loss of intervertebral disc space height at L3-L4 with active inflammation and edema. L2-L3: There is no focal disc herniation or spinal canal stenosis. L3-L4: Patient is post remote left laminotomy at this level. Irregular cystic soft tissue within the thecal sac is present without high grade spinal canal stenosis. Irregular soft tissue within the thecal sac extends towards the sacrum.
Remaining intervertebral disc space heights are preserved with varying degrees of mild disc desiccation. Spinal canal is mildly congenitally narrowed with subtle retrolistheses of L3 on L4, and L4 on L5. Cauda equina nerve roots are displaced and irregular extending from the conus to the distal thecal sac due to the intradural soft tissue and fluid collection. L1-L2: There is no focal disc herniation or spinal canal stenosis. Bilateral facet arthropathy encroaches upon the neural foramina resulting in mild-moderate foraminal narrowing. Abnormal soft tissue and enhancement within the thecal sac extends towards the sacrum.
On physical exam she is neurologically intact in her lower extremities. A flexion and extension radiograph is performed and shown in Figure A.
An axial CT myelogram at the L4/5 level is shown in Figure B.
Her neurological exam demonstrates difficulty with heel-walking and normal patellar tendon reflexes bilaterally. Figures A and B show a lateral x-ray and a sagittal MRI of her lumbar spine.
She has failed all previous conservative management and would like to proceed with surgery. A 44-year-old male presents with pain in the posterior aspect of his left thigh after walking more than 20 feet.