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Male patient in his mid-60s who had previously undergone an L4-S1 fusion by a different surgeon.
Since that time he has had severe paralumbar pain that has been progressively getting worse. He has undergone extensive multimodal conservative therapy, including physical therapy, pain management and spinal cord stimulator*, that showed no improvement and only worsening of his symptoms. Imaging showed severe proximal junctional breakdown above his previous fusion with reversal of lumbar lordosis with a pelvic incidence lumbar lordosis mismatch of 25 degrees and severe central foraminal stenosis at L3-L4 and L2-L3.
Given the pressing symptoms we recommended surgery and performed an L2 to L4 XLIF as a stage 1 operation and a stage 2 operation that included revision of the prior surgery, re-instrumentation and fusion from L2-S1.
The patient is doing well post-operatively and is recovering and doing physical therapy.
*Please note that the spinal cord stimulator that can be seen in the pre-op images had been removed prior to the surgery.
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