What is the best course of treatment for a patient with a history of CAD, type 2 DM, and multi-level lumbar spondylosis, presenting with low back pain and bilateral leg weakness?

Surgical Management: Multilevel Decompression with Selective Fusion

This patient requires multilevel lumbar decompression (L2-3, L4-5) with fusion limited to L4-5 only, based on the presence of documented instability at that level from prior laminectomy, moderate to severe stenosis, and facet hypertrophy. 1

Critical Decision Points for Fusion vs. Decompression Alone

Levels Requiring Decompression WITHOUT Fusion

L2-3 Level:

• Decompression alone is appropriate despite the left paracentral disc extrusion with severe left lateral recess narrowing and moderate spinal canal stenosis 1
• The American Association of Neurological Surgeons recommends decompression alone for lumbar spinal stenosis without evidence of instability 1
• No spondylolisthesis, no preoperative instability on imaging, and no evidence that extensive facetectomy will be required at this level 1
• The small right facet synovial cyst (4.5 x 2.4 mm) can be addressed during decompression without necessitating fusion 1

L3-4 Level:

• Only mild facet hypertrophy with mild foraminal narrowing—does not meet threshold for surgical intervention 1
• No significant disc bulging or spinal canal stenosis present 1

L5-S1 Level:

• Despite near complete disc height loss and Modic changes, there is only mild bilateral foraminal stenosis with patent spinal canal 1
• Fusion is only indicated at levels with documented instability or where extensive decompression will create iatrogenic instability 1
• The American Association of Neurological Surgeons provides strong evidence that only 9% of patients without preoperative instability develop delayed slippage after decompression alone 1

Level Requiring Decompression WITH Fusion

L4-5 Level:

• Fusion is mandatory at this level due to moderate to severe facet hypertrophy, ligamentum flavum thickening, moderate to severe bilateral foraminal stenosis, bilateral recess narrowing, and moderate spinal canal stenosis 1
• The combination of moderate to severe facet hypertrophy with the need for bilateral decompression creates high risk for iatrogenic instability (approximately 38% risk) 1
• The American Association of Neurological Surgeons recommends fusion when extensive decompression will create instability 1
• Instrumentation with pedicle screws is appropriate at L4-5, as it improves fusion success rates from 45% to 83% (p=0.0015) in patients requiring extensive decompression 1

Surgical Approach Algorithm

Step 1: Confirm Conservative Management Failure

• Patient presents with bilateral leg weakness and low back pain with neurogenic claudication symptoms 2
• MRI demonstrates multi-level pathology correlating with clinical symptoms 2
• Surgical intervention is appropriate when conservative management has failed and neurological deficits are present 2

Step 2: Address Comorbidities

• BMI 33, CAD s/p PTCA, and type 2 diabetes increase perioperative risk but do not contraindicate surgery in a patient with progressive neurological symptoms 3
• Optimize cardiac and glycemic control preoperatively 3
• Consider cardiology clearance given history of CAD 3

Step 3: Surgical Technique

• Perform bilateral decompression at L2-3 (laminectomy with foraminotomy and removal of disc extrusion and synovial cyst) 1
• Perform bilateral decompression at L4-5 with posterolateral instrumented fusion using pedicle screws and autograft 1
• Preserve as much facet joint as possible at L2-3 to avoid creating iatrogenic instability 1
• At L4-5, extensive facet resection will be necessary given the moderate to severe hypertrophy, which justifies the fusion 1

Critical Pitfalls to Avoid

Do NOT perform fusion at L2-3:

• Blood loss and operative duration are significantly higher in fusion procedures, and patients with less extensive surgery have better outcomes when instability is absent 1
• Adding fusion without documented instability increases surgical risk without proven benefit 1

Do NOT extend fusion to L5-S1:

• Despite radiographic degenerative changes, there is no documented instability or severe stenosis requiring decompression at this level 1
• Extending fusion unnecessarily increases adjacent segment disease risk and operative morbidity 1

Do NOT perform decompression alone at L4-5:

• The combination of moderate to severe facet hypertrophy requiring extensive bilateral decompression creates unacceptable risk (up to 73%) of progressive instability and need for revision surgery 1
• Decompression alone in this setting leads to progression of deformity and poor outcomes 1, 4

Management of the L1 Vertebral Body Lesion

• The 8 mm well-circumscribed T1 hypointense, T2 hypointense, STIR slightly hyperintense lesion is most consistent with a hemangioma or bone island 5
• This is an incidental finding that does not require intervention but should be documented 5
• If there is any concern for metastatic disease given the patient's age and comorbidities, consider CT-guided biopsy prior to surgery, though imaging characteristics are not suspicious for malignancy 6

Postoperative Neuropathic Pain Management

• If neuropathic leg pain persists postoperatively, consider pregabalin 75 mg twice daily, titrating to 150 mg twice daily (300 mg/day) within 1 week based on efficacy and tolerability 7
• Patients may be further increased to 225 mg twice daily (450 mg/day) if insufficient benefit at 300 mg/day 7
• Adjust dosing for renal function given diabetes and age 7

Expected Outcomes

• Approximately 97% of patients with symptomatic stenosis experience some recovery of symptoms after appropriate surgical decompression 4
• Limiting fusion to only the unstable level (L4-5) while decompressing other symptomatic levels (L2-3) optimizes outcomes while minimizing surgical morbidity 1
• The bilateral leg weakness should improve significantly with adequate decompression of the severe left lateral recess narrowing at L2-3 and bilateral stenosis at L4-5 4