Grand Rounds Case Presentation: Adjacent-Level Degeneration Following Multilevel Decompression and Fusion with Neuropathic Axial and Right Leg Pain

Abstract

Case Presentation: D.J. is a 58-year-old right-hand-dominant Caucasian woman who presented with a history of posterior interbody fusion (PLIF) L2-S1 in 2000 secondary to severe spinal stenosis L3-L5, severe degenerative disc disease of the lumbar spine L2-S1 with a Grade II dynamic anterolesthesis L3 on L4 and Grade I retrolesthesis L5 on S1. She awoke from the L2-S1 PLIF with severe burning dysesthesias across the lower aspects of the lumbar region and into the right buttock/posterior lateral right lower extremity; the lumbar dysesthesias lessened but did not completely cease (i.e., burning pain in the lumbosacral region continued, but sharp pain ceased); the right buttock and leg did not change (see Figure 1). Figure 1 Pain diagram. She trialed physical/manual therapy, aquatic therapy, epidural steroids (three series of three), gabapentin (3,600 mg/day), nortriptyline (100 mg qHS) without benefit. She presented taking the following medications: Fentanyl Transdermal 150 µg/h q2days Hydrocodone/acetaminophen 10/500 mg 2 tab q4h Tizanadine 8 mg qHS Metaxalone 800 mg QID Naproxen Sodium 250 mg BID 0.625 mg conjugated estrogens/2.5 mg medroxyprogesterone qday Gliburide 10 mg qAM She characterized the axial back pain as “constant,” “burning,” “searing,” “aching,” and “stabbing” with interposed “shooting” pain. She reported radiation of pain into the right buttocks and posterior/posterior lateral aspect of the right lower extremity utilizing similar descriptors. Over the 4–6 months preceding examination, she described a “popping” sensation in the low back with certain movements that worsens the right leg radicular symptoms. She reported pain 24 hours/day with only intensity fluctuations. She rated pain utilizing the Brief Battery for Health Improvement (version 2) (BBHI-2) (see Figure 2). Figure 2 BBHI. PTSD = post-traumatic stress disorder. Past Medical History: Adult-onset diabetes, hyperlipidemia. Past Surgical History: Anterior cervical discectomy and fusion (ACDF) C5-C72000; L2-S1 PLIF 2000. Allergies: Codeine/Morphine (rash). Social: Common law marriage with grown …