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. 2022 Jun;12(6):13-18.
doi: 10.13107/jocr.2022.v12.i06.2846.

Foraminal Stenosis at L5-S1 as an Overlooked Pathology of Bilateral Radiculopathy: A Case Series

Kohei Takahashi  1   2 , Ajay Kumar Yadav  1 , Ko Hashimoto  2 , Takumi Tsubakino  1 , Toshimi Aizawa  2 , Yasuhisa Tanaka  1
Affiliations

Foraminal Stenosis at L5-S1 as an Overlooked Pathology of Bilateral Radiculopathy: A Case Series

Kohei Takahashi et al. J Orthop Case Rep. 2022 Jun.

Abstract

Introduction: The classical symptom of foraminal stenosis is unilateral radiculopathy. Bilateral radiculopathy caused purely by foraminal stenosis is rare. Here, we report five cases of bilateral L5 radiculopathy caused purely by L5-S1 foraminal stenosis and describe the clinical and radiological features of these patients in detail.

Case presentation: Among the five patients, two were men and three were women with an average age of 69 years. Four patients had undergone surgeries at L4-5 level, previously. All the patients showed an improvement in symptoms in the post-operative period. After a certain period, the patients complained of bilateral leg pain and numbness. An additional surgery was performed in two patients; however, there was no improvement in symptoms. One patient, who did not undergo surgery, was treated conservatively for 3 years. All the patients had been suffering from bilateral leg symptoms before their first visit to our hospital. The neurological findings in these patients were consistent with bilateral L5 radiculopathy. The average pre-operative Japanese Orthopedic Association (JOA) score was 13 out of 29 points. Bilateral foraminal stenosis at L5-S1 level was confirmed using a three-dimensional magnetic resonance imaging or computed tomography. Posterior lumbar interbody fusion was performed in one patient and bilateral lateral fenestration using Wiltse's approach was performed in four patients. The neurological symptoms recovered immediately after surgery. The average JOA score at 2-year follow-up was 25 points.

Conclusions: Spine surgeons may overlook the pathology of foraminal stenosis, particularly in patients with bilateral radiculopathy. Familiarity with the clinical and radiological features of symptomatic lumbar foraminal stenosis is necessary to properly diagnose bilateral foraminal stenosis at L5-S1 level.

Keywords: Bilateral; L5–S1; foraminal stenosis.

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Conflict of interest statement

Conflict of Interest: Nil

Figures

Figure 1
Figure 1
Magnetic resonance images of the five cases. The number represents the case number. (a) Paramedian sagittal view of 2D MRI in the right side. (B) Paramedian sagittal view of 2D MRI in the left side. (C) Oblique coronal view of 3D MRI.
Figure 2
Figure 2
Schema of bilateral foraminotomy using Wiltse approach. The bone resection area was shaded. Asterisk indicates the pedicle of L5, while double asterisk indicates the pedicle of S1.
Figure 3
Figure 3
Myelograms and computed tomography after myelography (CTM) of case 1. (a) Lateral view of myelograms. (b) Anteroposterior view of myelograms. (c) Axial view of CTM at the L3-4 disk level. (d) Axial view of CTM at L4-5 disk level. (f) Axial view of CTM at L5-S disk level. Nerve root impingement in the spinal canal was not obvious and disk space narrowing and vacuum phenomenon at the L5–S1 disk level were observed.
Figure 4
Figure 4
(a) Selective radiculogram (SRG). (B) CT after SRG of case 1. Narrowing of the bony tunnel was confirmed by CT after SRG
Figure 5
Figure 5
Radiograms after posterior lumbar interbody fusion. (a) Anteroposterior. (b) Lateral.
See this image and copyright information in PMC

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