Medical History:
A 60-year-old male patient presented with a chronic history of lower back pain lasting for 8 months, which had progressively worsened over time. For the past 6 months, the pain radiates to both legs, significantly affecting his daily mobility and comfort. The patient reported increased discomfort during activities such as standing up, walking for prolonged periods, and even changing positions in bed. These symptoms were accompanied by neurogenic claudication—a condition causing leg pain due to nerve compression—lasting approximately 10 minutes during physical exertion. His clinical complaints and pain pattern were consistent with lumbar canal stenosis, primarily affecting the L4-L5 level of the spine.
Clinical Examination:
Upon physical examination, the patient displayed an abnormal gait tilted to the left. Evaluation of lumbar spine movements revealed:
- Flexion: Full and unrestricted
- Extension: Painful
Neurological assessment showed reduced sensation in the L4 and L5 dermatomes, confirming nerve involvement.
Diagnosis:
- L4-L5 Lumbar Canal Stenosis:
Narrowing of the spinal canal at the L4-L5 level, causing compression of nerve roots leading to back pain, leg discomfort, and neurogenic symptoms. - Surgical Procedure L4-L5 Posterior Spinal Fusion (Performed on 13/10/2023):A spinal stabilization surgery performed to decompress the affected nerves and fuse the L4 and L5 vertebrae, aiming to relieve symptoms and restore function.
Motor Strength Assessment (Lower Limb):
| Muscle Group | Right (Pre-op → Post-op) | Left (Pre-op → Post-op) |
|---|---|---|
| EHL (Extensor Hallucis Longus) | 5/5 → 5/5 | 4/5 → 5/5 |
| Ankle Dorsiflexion | 5/5 → 5/5 | 3/5 → 5/5 |
| Ankle Plantarflexion | 5/5 → 5/5 | 4/5 → 5/5 |
MRI Findings:
Magnetic Resonance Imaging (MRI) revealed degenerative changes at L4-L5 and L5-S1 intervertebral levels:
L4-L5: Disc protrusion compressing the thecal sac and nerve roots, with associated hypertrophy of ligamentum flavum and facet joints, resulting in focal spinal canal stenosis.
L5-S1: Mild posterior disc bulge along with ligament and joint changes, contributing to further narrowing.
These findings confirmed the diagnosis of lumbar canal stenosis, particularly severe at the L4-L5 level.
Postoperative Recovery and Discharge Condition:
The patient’s recovery was closely monitored until discharge on 16/10/2023. At the time of discharge:
- The patient was stable
- Sutures were clean and dry
- No signs of infection, fever, or chills
- The patient was able to climb stairs and bathe independently
- He was ambulating independently with full weight-bearing