Hi Dr. Tony Mork. Board-certified orthopedic surgeon endoscopic spine specialist, just over the last 14 years, having dedicated my practice exclusively the endoscopic spine surgery during that period of time for the treatment of chronic neck and back pain.
Today I’d 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 reoccurred. 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 one or two centimeters in diameter of really local or focal back pain, six centimeters to the left and mid line 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 a stenosis and the Foraminal canals. Just let’s take a look at his a CT of his lumbar spine you get a sense what I’m talking about here.
In this case you can see that we have multi-level degenerative disease, almost complete loss of the disc . That this bone on bone contact and spurs on the back of every level. So just, he’s got it everywhere, too i believe and oddly enough less at l-5 s-, than the other levels. he has foraminal stenosis that also occurs at each of these levels that correspond exactly with these type of findings.
Okay so here’s the clinical story, 82 years old, pain particularly with golfing ,and with lateral bending, multilevel stenosis and degenerative disc disease is seen, and 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 in exiting nerve root. I did a selected viewer block at of the L-3 nerve root as it exited L3-4 and got one hundred percent relief of his pain.
I didn’t continue the diagnostics any further than that with that I did a just a endoscopic trans-foraminal decompression which I will show you right now so as we see here on the left hand side there’s a trans facet decompression of the foraminal canal L3-4. The trans faceet decompression is seen here at L3-4 for as well and just take note of the other areas of significant foraminal stenosis at 2-3 and 4-5 & 5s 1 certainly.
This surgery gave him really complete relief of his pain for about three months. Then he started to develop a slow steady increase of left low back pain in the same area 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 facets 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 a 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 bending doing some lateral bending at the time of the injection he had complete relief of his pain.
So my final diagnosis was again the set syndrome after a successful decompression of the foraminal canal 3-4. This is going to be a perfect case for a wolf endoscopic facet rhizotomy in the event that his pain returns so far it’s been about a month or six weeks and his pain has not come back after the blocks that were performed at the time.
Well what have we learned here well number one I think spinal pain mapping is a great thing to do even after a primary surgery. It can which worked fairly well for just a few months but I think we had a complicating situation of facet syndrome. so what if what else have I learned about this certainly that looks like a selective nerve block maybe was responsible for blocking a portion of facet pain initially and that’s why he got partial relief with the trans-facet decompression and then had a return of facet to set pain number two I think spinal pain mapping is a great technique especially if you’re 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. Number three 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 well.
Hey listen I think that you could be a real hero by providing endoscopic the set surgery after successful spinal pain mapping and Facet blocks in this particular case even after the person’s had surgery. So again, I just think that this is a great way to go the blocks predict how much pain relief will most likely occur after a rhizotomy and in this case using the wolf endoscopic rhizotomy set which would be perfect for this situation.
Thanks a lot look forward to talking to you soon, take care.