Sciatica Sidelines a College Athlete

History

The patient is a 21-year-old female college varsity athlete who presents with a 4 month history of sciatica. Despite aggressive physical therapy and two separate nerve root injections, the severity of the symptoms forced the patient to step aside as a competitive member of a rowing crew team.

Examination

Symptoms include low back and left-sided buttock and leg pain. Pain also radiates into her foot. Her pain varies between 6 and 9 and worsens during athletic activity.

The neurological examination was normal with positive straight leg raise.

Prior Treatment

Under the university's trainer, the patient tried non-steroidal anti-inflammatory drugs and physical therapy.

Imaging

Figure 1. Sagittal CT scan shows a L5-S1 disc extrusion.
The bulge at L4-L5 was considered clinically insignificant.

Figure 2. Axial CT scan of L5-S1

Diagnosis

Extruded disc at L5-S1, paracentral location

Selected Treatment

Xclose™ Tissue Repair System (Anulex™ Technologies, Minnetonka, MN) allowed us to accelerate the patient's rehabilitation (aerobic conditioning started at 3 weeks) and, hopefully, prevent reherniation.

During surgery, a large extruded fragment was found with discrete anular disruption, which I repaired.

Xclose™ Tissue Repair System video demonstration

The Xclose™ Tissue Repair System is indicated for use in soft tissue approximation for procedures such as general and orthopedic surgery.

Outcome

The patient began aerobic conditioning exercises at 3 weeks postop. She returned to training at 4 weeks and competition at 6 weeks after surgery. So far, she has returned to competition with no evidence of herniation recurrence. The sagittal and axial MRI scans (Figures 3, 4, below) were taken at the patient's 4 month postoperative visit.

Figure 3. Postoperative sagittal CT scan

Figure 4. Postoperative axial CT

Patient Disclaimer: This case reflects one patient’s/surgeon’s experience.  Not every person will receive the same results.  Talk to your doctor about your treatment options.

Jason M. Highsmith, MD

Neurosurgeon

Charleston Brain and Spine

Anular repair represents an emerging technology with significant implications, especially in the young patient with a focal extruded fragment.

Personally, I would have tried an epidural steroid injection as the next line of treatment, especially with a normal neurologic exam. Free fragments such as this will often involute and resorb. However, if resorption alone were adequate, one would have expected some clinical improvement by 4 months post-injury. Furthermore, the anular defect would persist and may never reach the integrity provided by the open anular repair.

In this patient, the more aggressive intervention led to a shorter recovery and faster return to competition. The young age of this patient, combined with her thick anulus and well-defined, small defect made her a good candidate for anular repair.

Dr. Zdeblick has obtained a beautiful outcome clinically and radiographically with remarkably little trauma to the surrounding tissues on MRI.