This case involved a 19-year-old male patient who had a history of low back pain for about a year and was reporting severe, constant, and aching lower back pain of 8-9 on a scale of 10, as well as radicular right leg pain, decreased sensation on the right, difficulty straightening his right leg making it difficult to walk. An MRI showed a rather large L5-S1 herniated disk on the right side with severe degenerative disk disease.
The defendant performed an L5-S1 decompression with posterior lumbar interbody fusion and placement of a TraXis cage. Infuse and autograft were used to complete the interbody fusion. Intraoperatively, the defendant found that the patient had severe degenerative disk disease with a large right paracentral disk herniation, with the disk acting like a broad-based disk bulge with some components of hard and soft disk. There were no significant sequestered or extruded fragments, however.