Pitfalls in the Diagnosis and Treatment of Low Back Pain in an Elite Para-athlete Successfully Treated by Transforaminal Full-endoscopic Discectomy with Thermal Annuloplasty: A Case Reports

Abstract

We report a rare case of an elite para-athlete with lumbar disk herniation whose pain generator was difficult to diagnose and treat. A 28-year-old woman with paraplegia below the T10 level felt pain in her low back and left leg during a match. Magnetic resonance imaging revealed a lateral lumbar disk herniation and a high-intensity zone on the left side at the L5-L6 level. Because the pain disappeared following L5 selective nerve block, we performed transforaminal full-endoscopic discectomy alone. Despite the disappearance of leg pain after surgery, her low back pain persisted. We performed thermal annuloplasty because reproducible pain and subsequent temporary pain relief by discography and discoblock after the initial surgery indicated discogenic pain. Her suffering from back pain gradually reduced. She returned to competition 2 months after the second surgery without intensive rehabilitation due to difficulty in performing core exercises for abdominal muscles. During the return match, she experienced a relapse of pain in the low back and left leg, which was caused by a recurrence of disk herniation. We performed a full-endoscopic discectomy with thermal annuloplasty again. Her clinical symptoms were immediately relieved. We enhanced her thoracic spine flexibility to prevent subsequent recurrence. Finally, she returned to international competition 2 months after the third surgery. Close attention to para-athletes is required to achieve an accurate diagnosis of pain generators and prevent recurrence due to their distinctive disorders. Thermal annuloplasty and rehabilitating thoracic movement can be an excellent option for para-athletes with discogenic low back pain.

Keywords: discogenic pain; full-endoscopic spine surgery; lumbar disk herniation; para-athlete; recurrence.

Fig. 1

Preoperative images of radiographs (A, B), MRI (C-F), and CT images after discography (G-H). (A) Posteroanterior radiograph showing lumbarization. (B) Lateral radiograph. (C) Mid-sagittal T2-weighted MRI showing disk degeneration at the L4-L5 and L5-L6 levels. (D) Para-sagittal T2-weighted MRI. (E, F) Axial images of T2-weighted MRI showing lateral lumbar disk herniation (white arrow) (E) and a high-intensity zone (yellow arrow) (F) on the left side of the L5-L6 level. (G) Sagittal CT. (H) Axial CT showing contrast leakage via a posterolateral annulus fibrosus tear on the left side of the L5-L6 level. CT: computed tomography; MRI: magnetic resonance imaging

Fig. 2

MRI after the initial surgery showing disc degeneration at the L4-L5 and L5-L6 levels without Modic change and the recurrence of disc herniation. (A) Mid-sagittal T2-weighted MRI. (B) Mid-sagittal STIR MRI. (C) Para-sagittal T2-weighted MRI (D, E) Axial images of T2-weighted MRI. MRI: magnetic resonance imaging; STIR: short-tau inversion recovery

Fig. 3

Intraoperative endoscopic views during the second surgery and micrographs of the inflammatory granulation tissue with redness. (A) An intraoperative endoscopic view during resection of the inflammatory granulation tissue with redness (yellow arrow). (B) An intraoperative endoscopic view showing a damaged annulus fibrosus with redness (yellow arrow) at the annular tear (white arrow). (C) Micrograph of a hematoxylin and eosin-stained section showing granulation tissue with rich angiogenesis (yellow arrow) (magnification: ×20).

Fig. 4

MRI before the second surgery and the third surgery showing recurrent lateral disc herniation on the left side of the L5-L6 level. (A) Para-sagittal T2-weighted MRI before the second surgery. (B) Para-sagittal T2-weighted MRI before the third surgery showing a decrease in the T2-high area on the caudal side of the left L5 nerve root, indicating left L5 nerve root compression. (C) Axial T2-weighted MRI before the second surgery. (D) Axial image of T2-weighted MRI before the third surgery showing recurrent lateral disk herniation on the left side of the L5-L6 level. MRI: magnetic resonance imaging