Multi-Specialty Case Reviews: Post-laminectomy Syndrome

Post-laminectomy syndrome: physiatrist viewpoint

Regarding his imaging studies, his L5-S1 disk degeneration with significant disk space narrowing could be painful in itself, but the disk space narrowing may also place increased stress upon the L5-S1 facets, and may cause some degree of neuroforaminal narrowing around the left L5 nerve root.

Regarding his physical examination, has increased pain with lumbar extension suggests the possibility of facet pain, although some studies have questioned the association between lumbar extension and facet-based pain. His positive straight leg raising sign on the left suggests some element of left low lumbar nerve root irritation. Not mentioned on his physical examination was whether he exhibited tenderness over the left piriformis muscle, and whether his pain increased with simultaneous hip flexion and internal rotation, both of which would suggest that a portion of his pain is emanating from the left piriformis muscle. His increased pain with sitting also suggests some contribution from the piriformis muscle.

On his first visit I would recommend a trial of full dose acetaminophen at 1000 mg q.i.d. (provided that he does not consume more than 2 alcoholic beverages daily; if he does, a maximal dose of 500 mg q.i.d. would be indicated). A brief trial of an NSAID such as ibuprofen 200 mg, 3-4 t.i.d. may be warranted. Low-dose nortriptyline, 10 mg, 1-5 taken 1 hour before bedtime would be indicated both to improve sleep and to help reduce pain.

Initially, assuming that he has some tenderness over the left piriformis muscle and increased pain with simultaneous hip flexion and internal rotation, I would refer him back to physical therapy for a stretching program directed toward the left piriformis muscle, possibly preceded by ultrasound if his pain is severe. If this were ineffective, a corticosteroid/anesthetic injection to the piriformis muscle would be reasonable; these typically improve or eliminate the pain for up to 1 month at a time, during which period the patient should continue gentle but persistent stretching.

Physical therapy could also instruct him in lumbar spinal stabilization exercises, which might benefit whatever component of pain is emanating from his disk degeneration and facets.

If his symptoms persisted, a trial of a TENS unit or portable interferential current stimulator unit would be reasonable. An EMG of the left lower extremity may be indicated to look for evidence of significant left L5-distribution axonal damage with ongoing fibrillations. If an active radiculopathy or severe, chronic axonal damage were seen, a trial of gabapentin for neuropathic pain may be indicated. If nerve root irritation were seen in other nerves other than left L5, a CT myelogram may be reasonable to look for far lateral nerve root compression, which might be missed on the MRI.

If his symptoms continued, referral to a surgeon for consideration of a BAK cage fusion may be indicated.

By: John P. Revord, MD
December 14, 2000