Postoperative sciatica s/p

L4L5 posterior fusion

Upper Cheseapeake Medical Center Spine Conference Friday September 2, 2016

65 woman cc L sciaticaHPI 6 weeks sx PMH: RA, R TKA, HTN, anemia, paroxysmalAFIB, MEDS: lansoprazole, Metoprolol, antara, sertraline,Leflunomide, asa, humira,Digoxin, Cardizem, lyricaSH: marriedExam: 5’1” 188 lb

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

Note nerve rootFrom above lateralTo pedicle

Halo loosening sign

Halo loosening sign

No pain

R LBP buttock pain with radiation to anterior thigh and anterior leg

Sx started 3-4 weeks postoperativelycalled office 5 weeks postop and was given steroid packseen in office 7 weeks postop and examined, no infection, sent for imaging due to persistent symptoms

Images are 3 months postpo

5 weeks postop

DDX: Postoperative sciatica fusion

Early postop:Implant (screw) compressing nerveTraction neuropraxiaStenosis from disc, ligament, malalignmentInadequate decompressionRemoving distracting injury brings light to another painful problem

Late:InfectionNew stenosis, adjacent levelImplant looseningNot associated with surgery or spineHipPelvic or sacral fractureInstability

L3L4

L4

L4L5

L5

L5S1

L4

Superior L4

Inferior aspect L4

L5

R L4

thanks