General Discussion

Relatively healthy 81M with history of right L3/4, L4/5 open far lateral discectomies done in 2006 in NJ. Apparently this was complicated by nerve injury causing a period of profound RLE weakness. This eventually largely recovered, though he does have mild permanent deficits.

He presents now with progressive right low back/glute pain, as well as medial leg pain that radiates into the arch of the foot. This has been ongoing for several years (the foot pain being the most recent development), with the back and foot pain being most severe. He's undergone right L3/4 and L4/5 TFIs with about 50% improvement for several days. Podiatry has evaluated the foot and did not identify any intrinsic pathology. An EMG reported a chronic L4 radiculopathy, without evidence of tarsal tunnel syndrome. He was referred for minimally invasive decompression and is not very keen on a fusion. He does state that even if we were able to replicate the 50% improvement from his injections, he would be thrilled. 

I didn't detect any weakness on my exam though he reports notable differences in leg strength when resistance training. Some decreased L3 and L4 sensation on the right.

His imaging shows severe foraminal stenosis at L3/4 and L4/5. There is significant scar tissue in the far lateral region best seen on the axial MRI cuts. CT shows a significant bony component to the stenosis.

Curious to what to do here, including whether surgery should be offered at all. I am concerned that even with a technically successful operation, between the scar tissue potentially adherent to the nerve and a known history of nerve injury, he may not see significant improvement. We discussed that the scar elevates the risk of intraoperative injury to the nerve. Then, if surgery is offered, which level(s) and which approach? Transforaminal foraminotomy would usually be the most straightforward but with all of that scar I worry about the risk of nerve injury while trying to dissect through it. I’d likely just stick to the bone, drill off the ventral SAP tip and call it a day. Alternatively, could consider a contralateral sublaminar foraminotomy to identify the nerve root early and largely bypass the scar tissue. And which levels? Both levels are tight, but only L4 was identified on EMG and it's unlikely that L3 is contributing at all to the foot pain. Normally I'd address both, but with the elevated risks I think "less is more" certainly applies here.