PMC5054643_01
Imaging study after first surgery (right hemi-laminectomy and foraminotomy at L5-S1). Lumbar computed tomography (CT) myelogram during several month follow-up; (a) Transverse plane view at L5-S1; (b) Sagittal plane view. Lumbar Magnetic resonance imaging (MRI) during a 1-year follow-up; (c) Transverse plane view at L5-S1; (d) Sagittal plane view
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F1
Several months post-surgery, a computed tomography (CT) scan of the lumbar spine with contrast showed mild disc bulges at L5-S1, left neural foraminal narrowing at the L4-L5 and L5-S1 levels and right L5-S1 foraminal narrowing [Figure 1a and b]. The right L5-S1 nerve root was decompressed from the scar tissue of his previous surgery seen on MRI [Figure 1c and d].
Imaging studies after third surgery (approximately 2 years after first surgery): An L5-S1 instrumented lumbar spine fusion with bilateral rod placement. Lumbar computed tomography (CT); (a) Transverse plane view at L5-S1 with BMP-induced exuberant intradiscal and intraforamina bony formation (white-dash arrow); (b) Coronal plane view with early encroachment of foramen bilaterally (white arrows); (c) Lumbar MRI at L5-S1 (transverse plane view) with evidence of heterotopic ossification at L5-S1. One-third and two-thirds of right L5-S1 neuroforamina occupied by exuberant bony growth. Progressive nerve root disfigurement (white arrow) and intracanalicular and intradiscal encroachment due to BMP-related exuberant bony formation and failure of surgical drilling
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F2
On subsequent follow-up imaging studies after the third spine surgery, exuberant bony formation [Figure 2a and b] was found and narrowing of the L5-S1 right foramina with nerve root compression [Figure 2c] and probable arachnoiditis.
Lumbar imaging studies after 4th surgery (approximately 5 years after 1st surgery) - removal of hardware on the right and drilling out to remove osteophytic, exhotropic, heterotopic, and myxotrophe bone. Lumbar X-ray; (a) Antero-posterior (AP) view; (b) Lateral view:hardware is in place with open R-sided foramen; heterotopic bone growth is entangling all around the nerve root in the facet. Lumbar computed tomography (CT) confirmed heterotopic bone growth reaches and was able to grow in difficult places; (c) Transverse plane view; (d) Sagittal plane view showing remaining bone and entanglement of the right S1-nerve root, intradiscal and intraforaminal without respect for neural elements; (e) Transverse plane view; (f) Coronal plane view demonstrating post-surgical drilling of the exuberant bony formation when compared to right and left sides; bone growth is in continuity with disc post-lumbar fusion; significant amount of bone is drilled out on the right when compared to the left. (g) Sagittal plane view (T2 sequence); (h) Sagittal plane view (STIR sequence); (i) Transverse plane view (T2 sequence) showing foramen of new bone with incomplete bone removal after right screw removal and surgical drilling
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F3
An optimal widening of the right foramina required a removal of ipsilateral screw and other right-side instrumented fusion hardware [Figure 3a and b]. CT and MRI scans [Figure 3c-i] of the lumbosacral spine showed unilateral hardware at the left L5-S1; exuberant bony osteophyte formation with compressive elements occupying two-thirds of the right L5-S1 foramina; and impingement of the traversing nerve root; arachnoiditis, scarring, and postoperative changes.
Lumbar X-ray after Spinal Cord Stimulator (SCS) implantation; (a) Anterior-posterior view showing lead placement in T8-T10 connected to the IPG generator with restore-sensor on the right; (b) Lateral view confirms leads position in the epidural space; (c) Lumbar X-ray at 2 months after SCS implantation with lateral views confirming position of leads in the epidural space and placement at T8-T10
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Pleased with the trial outcome, the patient was implanted with the permanent double Medtronic Vectris SureScan MRI percutaneous leads at T8-T10 level, and connected to the IGP generator with a RestoreSensor SureScan MRI neurostimulator [Figure 4a and b]. Over the course of the neuromodulation therapy, he had not noted any fever, erythema, drainage, or swelling, and follow-up X-ray confirmed the placement of the leads without migration [Figure 4c].