Patient History

 A 70 year old female presented with sudden onset of radiating right L5 distribution leg pain and numbness, with complete right foot drop (0/5 ankle dorsiflexion strength). Medical history included diabetes and obesity (weight 231, BMI 41). Pre-op upright flexion lateral lumbar X-ray (Figure 1) demonstrates grade 1 anterolisthesis at L4-5 and grade 2 anterolisthesis L5-S1. MRI (Figures 2 and 3) demonstrates a right paracentral L5-S1 disc herniation tracking cephalad behind the L5 vertebral body. A brief course of conservative management was attempted but surgical intervention was offered early due to her significant neurological deficit.

Surgical Outcome:

 L5-S1 hemilaminectomy and discectomy were performed with successful extraction of a large free fragment medial to the right L5 pedicle. Fusion was performed due to the instability demonstrated on upright x-rays at L4-5 and L5-S1. A small PROLIFT interbody device (12mm x 8mm x 8-13mm) was inserted through an oblique TLIF trajectory at L5-S1. 

Despite the patient’s challenging medical history, the procedure provided rapid and complete resolution of right foot drop, leg pain, and numbness. The patient was discharged on POD5. In short term follow-up, there was no cage subsidence or collapse.