Case Studies / Michaela
Case Study

Michaela

Problem

Michaela presented with an ache in her left shin and occasionally in her right leg resulting from a fall. She denies any paraesthesia. The intensity of pain was rated as a 7/10 to 10/10.

The MRI of her lumbar spine shows evidence of degenerative discs at both the L4/L5 and L5/S1 spinal levels. There is further facet degeneration and hypertrophy at these spinal levels.

This has resulted in lateral recess narrowing bilaterally at the L4/L5 spinal level.

The clinical indication was that Michaela's recurring back pain was a result of degenerative changes at the L4/L5 spinal level.

Solution

Initially, Mr. Kelleher pursued a non-invasive treatment plan. Michaela received facet and nerve root block injections with a view to reducing the severity of the pain.

Unfortunately, Michaela received no benefit from either set of injections. A review of her MRI imaging showed further degeneration at the L4/L5 and L5/S1 spinal levels.

Mr. Kelleher subsequently organised a referral to Dr. Tamilmani, pain management consultant, for further pain reduction procedures.

Further imaging indicated a continued deterioration and at this point Mr. Kelleher decided that a fusion of the L4-S1 spinal levels was the best course of action.

Michaela underwent a L4/S1 spinal fusion, decompression and interbody cage procedure and reported a 75% reduction in pain.

Her words

I have suffered on and off with back pain for a number of years. In 2018 my GP referred me to Mr. Michael Kelleher in the Sports Surgery Clinic.

I had an MRI in SSC in, I think it may have been June 2018. Mr Kelleher took a cautious approach and initially I underwent pain management via injections. I had a further MRI in April 2019 and following this MRI Mr. Kelleher said that he would perform surgery - spinal fusion on L5 to S1 in May 2019.

My thanks must go to Mr. Kelleher and his team for looking after me so well and now two years post surgery I have never looked back. I still get bouts of back pain but nothing like I had pre-surgery. Before I had the surgery I was in constant agony now the pain is completely manageable. I just need to be careful and continue my exercises.

Again, I reiterate my thanks to Mr. Kelleher.

M

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