Orange County Register

Reader Marsha Gallavan asks a doctor whether there are any non-surgical or other minimally invasive procedures to remedy her husband’s back problems. Dr. Charles Rosen, who founded the UCI Spine Center and the Association for Ethics in Spine Surgery, discusses the options.

Q. My husband is 71. He had a spinal fusion with instrumentation at L4-5 in 2003. For the past six months, he has experienced lower back pain again. Since September, he has also had pain (in the front of the thigh) and weakness/numbness in his left leg only. He has fallen four times due to the leg weakness. He now uses a cane, but he can’t walk far and cannot exercise as he did before September.

Within the past six weeks, he has had an MRI, EMG, CT Myelogram and lumbar xrays. The diagnosis is a herniated disk at L3-4, pressing on the L3 nerve. He also has disk degeneration at L2-3 and slight spondylolisthesis (Grade 1) at L3-4.

Three surgical opinions have recommended fusion at L3-4. Two surgeons will go in from the back; the other will go in from the side (XLIF) and the front. One surgeon also recommends fusion at L2-3; the other two will do laminotomies at L2-3.

My questions: 1) Is there any nonsurgical or less-invasive option to decompressing the nerve and returning function to the left leg? That’s our biggest concern. I know that some people are treated by physical therapy. However, in the past, such therapy hasn’t worked for my husband’s back pain.

2) I researched minimally invasive surgery, but the surgeons I went to discouraged it or, in one case, wanted to combine such a procedure with an anterior approach, too. Four hours on the table is too much! Do you know of other surgical options?

My husband’s other medical problems (e.g. leukemia) make us even more wary than usual of surgery. I’ve done lots of research and am willing to do anything to make sure my husband has a successful outcome.

Thank you,

Marsha Gallavan

Click on for Dr. Rosen’s answers.

A. For your first question, let me say that the important distinction here is that he is falling because of his quadriceps weakness as a result of the L34 herniation. This makes it more of an urgent situation since he could fall and break his hip if this isn’t going away on its own within a month or two. So if this is the case, then surgical intervention is called for if it’s not resolving. There is no other way I know of to more reliably address this when there is direct compression of the nerve that has to be physically relieved of the pressure on it.

For your second question, don’t get overly enamored with the term ” minimally invasive.” It’s a buzz word people erroneously think is always better and means less surgery. Sometimes it can speed recovery and be very effective in its results. But also it can sometimes mean longer surgery, less reliable results, and sometimes more serious complications. I wouldn’t elect for it in this situation for some of these reasons. My suggestion would be, based on your information, to do a laminotomy along with a fusion of the disc space with cages and a fusion on the sides of the vertebra as well. This can be done expeditiously from behind without the need for going through the abdomen in this situation, and would give the most reliable results. Additionally, I see no reason to fuse L23 for “degeneration” alone - which most of us have - without there being a herniation, spondylolisthesis or instability. It adds significant time - keeping in mind the leukemia - and complication rate.

All surgery has risks and there is no way to “assure” a successful outcome. There is only a way to choose the options that have the highest chance of success in a particular situation based on the risk of not doing something.

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