1338 - Unraveling Back Pain Years After Hybrid Lumbar Surgery: A Case Report on Index Level and Adjacent Segment Facet Arthropathy

A 64-year-old male with a history of lumbar discectomy (1999) as well as L4-5 lumbar disc arthroplasty and L5-S1 anterior lumbar interbody fusion (2014) presents with new-onset low back pain. Physical exam revealed moderately rigid lumbar paraspinal muscles with TTP bilaterally and pain with lumbar facet loading bilaterally.

MRI Lumbar Spine revealed facet arthropathy and mild disc dessication with disc bulging at the L1-2, L2-3, and L3-4 levels, with evaluation at L4-5 limited due to postoperative changes. Mild neuroforaminal stenosis was additionally revealed at the L3-4 and L5-S1 levels, as well as notable levoscoliosis.

Prior conservative measures (e.g., bracing, physical therapy, oral medications) were unsuccessful. Bilateral L2-4 medial branch blocks were completed following clinical suspicion for facet arthropathy as a potential pain generator. Patient had 80% pain relief with each of the two medial branch blocks before completing bilateral L2-4 RFA, which resulted in 50% pain relief.

Discussions: This case highlights the development of symptomatic facet arthropathy years following hybrid lumbar spine surgery in the setting of multiple potential pain generators, confirmed by successful radiofrequency ablation. Spondylotic changes are observed at both the arthroplasty level and adjacent segments following hybrid lumbar spine surgery, with development and progression affected by factors such as pre-existing spondylosis, altered biomechanics, and surgical instrumentation. The extent of pre-existing facet arthropathy and disc degeneration is unknown in the setting of the patient’s prior lumbar discectomy.

Conclusions: Facet arthropathy at the level of disc arthroplasty and of the adjacent segments should be considered in the differential diagnosis for persistent low back pain in the years following hybrid lumbar spine surgery. The prevalence of facet arthropathy in this population merits further research to better understand its likelihood and to improve long-term patient outcomes as the popularity of the procedure grows.