A Case Report | Sunday Observer

A Case Report

25 April, 2021

A 73-year-old woman from the Western Province came to see me in clinic a week ago. She had severe lower back pain with shooting pain down the right leg. This has been going on since the year 2010. She had lived in England during that time. Her X ray of the spine has shown a spondylosthesis at L3 and L4 vertebrae. Spondylosthesis is slipping of vertebrae over another vertebrae. In her case the upper vertebral column is slipping over the 4t Lumbar vertebrae (L4).

X ray evidence of the skip. Contour marked in black

She had been to a neurosurgeon and appropriately the surgeon has carried out spinal surgery in 2020 and stabilised the spine to prevent further injury. Stabilisation was done inserting 2 metal screws. This would prevent further injury particularly the spinal cord getting pressurised. But her symptoms of lower back pain and Sciatica did not get better with surgery. Pain persisted hence visit to consultant in pain medicine.

X ray with metal screws

I did examine her in my consulting suite I found that her Lumbar facet joints and the right sacroiliac joint were tender. I diagnosed facet joint arthropathy of the lumbar spine and right sacroilitis. Her sciatic leg pain on the right leg is coming from L4/L5 discs with pressure on the Right L5 nerve root.

I carried out a procedure last Thursday.

It was L2/3 L3/4 L4/5 L5/S1 facet injections on both sides and a right sacroiliac joint injection under X ray guidance.

Caudal Epidural

To treat her sciatic pain I did carry out a caudal epidural with an Epidurogram (with contrast into the epidural space). What was evident from the X’ray picture was that her right side has a block and the contrast could not penetrate the right side. This is why she has pain in the right leg which is due to the tightening and pressure on the right L5 nerve. This is an important bit of evidence which cannot be seeing in the MRI scans. If she is due to have any more spinal surgery the surgeon would know where to concentrate.


All the procedures were carried at the same time in an operating theatre with the aid of a continuous X’ray.

This was the procedure and not an injection as some call it. Injection is where a needle is introduced to a muscle or a joint. But this kind of procedure is called an interventional

MRI Scan of the spine. Degenerative spine

procedure which is more complex than a simple injection. But we do not use a scalpel and cut any muscle or tissue. We use probes and spinal needles which are much longer.

We have to wait and see how this lovely woman is going to respond. I have to say she is a fantastic patient with good communication skills. All pictures given to the patient in a CD.