Fig. 5

Semirigid inclusion of the cranial motion segment after IGD. a-c T2-weighted magnetic resonance images preoperatively: a lumbar sagittal image and b axial lumbar image of L3/4 and c L4/5. d Lateral radiographic image preoperatively and e postoperatively. The patient presented with chronic lumbar back, strong sciatic pain bilaterally, and a hypoesthesia at the right lateral lower leg. Moderate intervertebral disc degeneration was observed at L3/4 and L5/S1 (Pfirrmann grade 3), advanced degeneration at L4/5 (Pfirrmann grade 4-5), and a neuroforaminal stenosis on the right side due to facet joint hypertrophy and intervertebral disc protrusion (grade 2 according to Lee [16, 17]). Moderate facet joint degeneration was seen at L3/4 and L4/5 (Weishaupt grade 1). Recommendation before inpatient gradual diagnostics (IGD): lumbar fusion of L4/5 with transforaminal lumbar interbody fusion (TLIF). Results obtained during IGD: • bilateral facet joint infiltration of L3/4: 30 % pain relief back pain. • bilateral facet joint infiltration of L4/5: 30 % pain relief back pain. • epidural injection of L4/5: 30 % sciatic pain relief. • bilateral sacroiliac joint infiltration: 0 % pain relief. Although the absolute values for pain relief were only at moderate levels, the patient’s walking distance increased dramatically after the infiltrations. Recommendation after IGD: lumbar fusion of L3-5 with TLIF L4/5 and a semirigid instrumentation of L3/4. At the 3-month follow-up, the patient reported considerable pain relief and an increase in walking distance in comparison to that achieved preoperatively