USC Neurosurgery Case of the Month: Los Angeles, California

63 year-old gentleman has had low back pain that worsens on standing for prolonged periods and left leg tingling with pain radiating to his foot for the last two years. A significant portion of his debilitating pain was from his back. He underwent physical therapy and was placed on several medications for pain relief including narcotics and a muscle relaxant. Despite medical management, his back pain did not improve. Figure 1 A and B show patient’s AP and lateral lumbar x-rays.

He received a magnetic resonance imaging (MRI) of the lumbar spine and was noted to have degeneration of the L4-5 disc with decreased height and L5 nerve root impingement by a herniated disk at the same level (Figure 2a and 2b). He underwent further work-up to assess if his back pain was related to his L4-5 disc.

He sought the advice of our neurosurgeon and Spine specialist Dr. Michael Wang who counseled him on his options – ranging from conservative management to fusion of his back. The patient opted for placement of an artificial disc or lumbar disc arthroplasty.

He underwent the Charite ® disc arthroplasty at L4-5 level without complications.

He was taken to the operating room and positioned with his belly up. Under general anesthesia, a horizontal 7 cm incision was made on his abdomen to the left of his belly button. The midline spine was exposed after reflecting to the side his intestines and blood vessels. A diskectomy was performed carefully using a high-power microscope (Figure 3). The irritated left L5 nerve root was successfully decompressed from this approach. The Charite artificial disc was placed (Figure 4) and the patient’s disc height and curvature were improved (Figure 5).

The first day after surgery, patient was on morphine and toradol for pain control and stated that he had minimal to no pain except for the incisional pain. He was smiling and having his regular breakfast as soon as 12 hours after surgery. He got out of bed and walked 200 feet on the first day after surgery without assistance and without the need of a brace or walker. He was discharged home on the third day after surgery.

Figure 1a: Lumbar Spine

Figure 1b: Lumbar Spine

Figure 2a: L5 nerve root impingement by a herniated disk

Figure 2b: degeneration of the L4-5 disc

Figure 3: Microscopic diskectomy

Figure 4: Charite Artificial Disc

Figure 5: Postoperative scan with Charite Artificial Disc in place