Spine Conference: case of postoperative sciatica following a successful spinal fusion due to a pedicle fracture nondisplaced

1. Postoperative
sciatica s/p L4L5
posterior fusion
Upper Cheseapeake Medical Center Spine Conference
Friday September 2, 2016

2. 65 woman cc L sciatica
HPI 6 weeks sx PMH: RA,
R TKA, HTN, anemia, paroxysmal
AFIB,
MEDS: lansoprazole,
Metoprolol, antara, sertraline,
Leflunomide, asa, humira,
Digoxin, Cardizem, lyrica
SH: married
Exam: 5’1” 188 lb

4. L4L5 PSF R PICBG, L L3L5 decompression, L4L5 discectomy with L L4
Hemilaminectomy; Intraoperatively R L4 screw had poor purchase, removed, palpated and the
Screw was reinserted increasing the diameter from 6mm to 7mm

12. Note nerve root
From above lateral
To pedicle

14. Halo loosening sign

15. Halo loosening sign

19. No pain

20. R LBP buttock pain with radiation to
anterior thigh and anterior leg
Sx started 3-4 weeks postoperatively
called office 5 weeks postop and was
given steroid pack
seen in office 7 weeks postop and
examined, no infection, sent for imaging
due to persistent symptoms
Images are 3 months postpo
5 weeks postop

21. DDX: Postoperative
sciatica fusion
Early postop:
Implant (screw) compressing nerve
Traction neuropraxia
Stenosis from disc, ligament,
malalignment
Inadequate decompression
Removing distracting injury brings
light to another painful problem
Late:
Infection
New stenosis, adjacent level
Implant loosening
Not associated with surgery or
spine
Hip
Pelvic or sacral fracture
Instability

25. L3L4

26. L4

27. L4L5

28. L5

29. L5S1

31. L4

33. Superior L4

34. Inferior aspect L4

35. L5

37. R L4

46. thanks