Fig. 4

Recommendation for conservative treatment. a-c T2-weighted magnetic resonance images preoperatively: a lumbar sagittal image and b axial lumbar image of L4/5 and c L5/S1. d Lateral radiographic image. The patient presented with predominantly chronic lumbar back pain since childhood and intermittent bilateral sciatic pain. The patient works as a storeman. Advanced intervertebral disc degeneration was observed between L5 and S1 (Pfirrmann grade 4) and mild facet joint degeneration of L4/5 and L5/S1 (Weishaupt grade 1). Before inpatient gradual diagnostics (IGD), a lumbar fusion of L5/S1 with transforaminal lumbar interbody fusion had been discussed. Results obtained during IGD: • epidural injection of L5/S1: 0 % improvement of sciatic pain, 30 % back pain relief. • bilateral facet joint infiltration of L5/S1: 0 % improvement of back and sciatic pain. In view of the lack of response to the infiltrations, further conservative strategy was recommended. Half a year later, the patient had a discectomy of L5/S1 performed in another hospital, with initial good results for a few weeks, followed by a complete clinical relapse. When the patient thereupon presented himself in the department of neurosurgery of our hospital, our colleagues advised against further surgery, independent of our own recommendation