Case of the Week 85 Courtesy of Thomas Regez, DC

1. Case of the Week 85Courtesy of Thomas Regez, DC 49 year old female presented with acute LBP without radiculopathy. Relevant history includes Disc Surgery in 1993. Prior to that she received several crystal cortisone injections.

2. Radiographs taken in 2010 upon presentation to Dr. Regez

3. What are the abnormal findings? What is the diagnosis? What is the clinical significance?

4. Answers • Abnormal findings • Surgical bony spondylodesis (fusion) of the posterior elements of L4-5 are noted. There is also the suggestion of bony inter-body fusion at this level. • Multiple soft tissue ossifications superimposed over the lateral aspects of both iliac bones. • Narrowing of the L5-S1 disc space. • Diagnosis • Posterior element and interbody bony fusion L4-5 • Injection granulomas • Degenerative disc disease L5-S1 • Clinical Significance • The injection granulomas, although large, are of no significance and are due to fat necrosis from the medication. • The large bony fusion most likely includes inter-transverse bone graft along with the interbody and laminar involvement. This was done 17 years ago and was a common procedure (input from Dr. Baet Wälchli, DC, MD) until the mid 80s. It is not unusual for these fusions to be incomplete. The literature confirms that a substantial number of these patients continue to have movement at the ‘fused’ level (up to 40% of pts). However, the clinical outcome is still similar to instrumented posterolateral fusion and with less complications. Instrumented fusions do allow for the reduction of spinal deformaties however, and patients do not then have to wear a plaster post-operatively for a prolonged period of time (per Dr. Wälchli).