Facet Syndrome After Transfacet Decompression
Hi, I'm Dr. Tony Mork, board-certified orthopedic surgeon, endoscopic spine specialist over the past 14 years, having dedicated my practice exclusively to endoscopic spine surgery during that period of time for the treatment of chronic neck and back pain.
Today I would like to talk about a case that I saw in the office earlier this year and then more recently. This is a case where spinal pain mapping really helped me to identify the pain generators originally and then once again when the pain recurred.
In this particular situation, this is an 82-year-old gentleman with spondylosis throughout the lumbar spine, multilevel stenosis, and a very small area (maybe 1 or 2 cm in diameter) of really local or focal back pain, 6 cm to the left of midline at about the L3-4 level. When I saw this gentleman, I didn't exactly know what it was. I really got a sense it was stenosis in the foraminal canals.
On CT of his lumbar spine you get a sense of what I am talking about here. In this case you can see that we have multilevel degenerative disc disease, almost complete loss of the disc, bone-on-bone contact and spurs on the back at every level. So, he has it everywhere and oddly enough, less at L5-S1 than the other levels. He has foraminal stenosis that also occurs at each of these levels that correspond exactly with these type of findings.
OK, so here is the clinical story: Eighty-two-years old, pain particularly with golfing and with lateral bending. Multilevel stenosis and degenerative disc disease is seen, and so I decided that since the pain was so focal in nature, over to the left of midline, that it may have been stenosis affecting an exiting nerve root. I did a selective nerve root block at the L3 nerve root as it exited at L3-4 and got 100% relief of his pain. I did not continue the diagnostics any further than that.
With that, I did an endoscopic transforaminal decompression which I will show you right now. So, as we see here on the left-hand side there is a transfacet decompression of the foraminal canal, L3-4. The transfacet decompression is seen here at L3-4 as well, and just take note of the other areas of significant foraminal stenosis at L2-3, L4-5 and L5-S1 certainly. This surgery gave him really complete relief of his pain for about three months, and then he started to develop a slow, steady increase of left low back pain in the same area as before. So I told him, I said let's go back and do some more spinal pain mapping, and this time I thought, well I'll just give the facet joint a try. I didn't really think it was the facets because the pain was so local and so focal, but I tried the facets. Sure enough, as we look at here in the picture, injecting 1% xylocaine mixed with some Depo-Medrol into the base of the transverse processes above and below the area of pain and then let him move around like he was playing golf and doing some lateral bending at the time of the injection, he had complete relief of his pain. So my final diagnosis was again facet syndrome after a successful decompression of the foraminal canal at L3-4. This is going to be a perfect case for a Wolf endoscopic facet rhizotomy in the event that his pain returns. So far it has been about a month or six weeks, and his pain has not come back after the blocks that were performed at that time.
Well, what have we learned here? Number one, I think spinal pain mapping is a great thing to do, even after a primary surgery which worked fairly well for just a few months, but I think we had a complicating situation of facet syndrome. So, what else have I learned about this?
1. Certainly it looks like a selective nerve root block maybe was responsible for blocking a portion of facet pain initially, and that is why he got partial relief with the transfacet decompression and then had a return of his facet pain.
2. I think spinal pain mapping is a great technique, especially if you are anticipating doing a possible surgery; and again I think it reproduces what the patient will experience after getting a rhizotomy using the Wolf endoscope in this particular case.
3. I think this shows again how asymptomatic, very significant foraminal stenosis can be when people have this back pain, which can just be from the facets themselves.