J Neurosurg Case Lessons 5(12): CASE2317, 2023

DOI: 10.3171/CASE2317

Iatrogenic contralateral foraminal stenosis following lumbar spine fusion surgery:

illustrative cases
Faisal Konbaz, MD,1 Sahar Aldakhil, MD,2 Fahad Alhelal, MD,2,3,4 Majed Abalkhail, MD,2,3,4 Anouar Bourghli, MD,1 Khawlah Ateeq,2 and
Sami Aleissa, MD2,3,4
1
Department of Spine Surgery, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia; 2Department of Orthopedics, King Abdulaziz Medical City, Central
Region, National Guard Health Affairs, Riyadh, Saudi Arabia; 3College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; and
4
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia

BACKGROUND Lumbar spine fusion is the mainstay treatment for degenerative spine disease. Multiple potential complications of spinal fusion have
been found. Acute contralateral radiculopathy postoperatively has been reported in previous literature, with unclear underlying pathology. Few articles
reported the incidence of contralateral iatrogenic foraminal stenosis after lumbar fusion surgery. The aim of current article is to explore the possible
causes and prevention of this complication.
OBSERVATIONS The authors present 4 cases in which patients developed acute postoperative contralateral radiculopathy requiring revision surgery.
In addition, we present a fourth case in which preventive measures have been applied. The aim of this article was to explore the possible causes and
prevention to this complication.
LESSONS Iatrogenic foraminal stenosis of the lumbar spine is a common complication; preoperative evaluation and middle intervertebral cage
positioning are needed to prevent this complication.

https://thejns.org/doi/abs/10.3171/CASE2317
KEYWORDS spine; decompression; lordosis; complications; spondylolisthesis; radiculopathy

Lumbar spine surgery for degenerative conditions reduces pain and
disability and improves function.1 Many degenerative pathologies require
fusion to optimize surgical outcomes. There are several fusion methods,
such as posterolateral fusion, transforaminal lumbar interbody fusion
(TLIF), anterior lumbar interbody fusion, and lateral lumbar interbody fu-
sion (LLIF).2 Previous studies have reported many possible complica-
tions after spinal fusion, including ipsilateral nerve injury, wound
infections, recurrent pain, and cerebrospinal fluid leak.3 Acute contralat-
eral radiculopathy postoperatively has been reported in previous litera-
ture, but the underlying factors that are involved in contralateral disc
herniation were unclear in each situation.3 Lately, rich evidence has
been published and adapted by spine surgeons, which discusses the im-
portance of global spine alignment, particularly pelvic incidence (PI)–
lumbar lordosis (LL) matching.4 PI-LL mismatch is associated with poor
short- and long-term outcomes, including adjacent segment disease and
acquired adult spine deformity.5 This has led many surgeons to aim to
increase LL during fusion surgery to avoid PI-LL mismatch. However,
few studies have highlighted the relationship between increased LL and
iatrogenic foraminal stenosis.3,6–8 This complication has been recognized
3 times in our institution, where patients require revision surgery. We pre-
sent these cases for illustration. In addition, we present a fourth case in
which preventive measures were applied. This study aimed to explore
the possible causes of postoperative contralateral radiculopathy and pre-
ventive measures for this possible complication.
Illustrative Cases
Case 1
A 63-year-old woman with hypertension complained of lower
back pain with radiculopathy in the right lower limb and neurogenic

ABBREVIATIONS ASD 5 adjacent segment disease; CT 5 computed tomography; LL 5 lumbar lordosis; LLIF 5 lateral lumbar interbody fusion;
MRI 5 magnetic resonance imaging; PI 5 pelvic incidence; TLIF 5 transforaminal lumbar interbody fusion.
INCLUDE WHEN CITING Published March 20, 2023; DOI: 10.3171/CASE2317.
SUBMITTED January 11, 2023. ACCEPTED February 10, 2023.
© 2023 The authors, CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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 FIG. 1. Case 1. Immediate postoperative CT scans of the lumbar spine showing extension of fusion to L3
without evidence of screw malpositioning, adequate right L3–4 decompression, and severe iatrogenic left
L3–4 foraminal stenosis due to an osteophyte from the superior articular process of L4 facet joint resulting in
left L3 radiculopathy. Note the amount of L3–4 lordosis created with the instrumentation.

claudication. The patient had a history of L4–5 decompression and Case 3

fusion 7 years prior. The patient had no neurological deficits. Lum- A 50-year-old woman with no prior medical illnesses presented
bar spine radiography and magnetic resonance imaging (MRI) to the clinic complaining of progressive left leg radiculopathy and
showed solid fusion at L4–5 with interbody fusion without loosening,
an adjacent degenerative spinal stenosis and retrolisthesis of L3–4,
and right lateral recess and foraminal stenosis at the L3–4 level. Af-
ter failed conservative treatment, the patient underwent extension of
the fusion to L3 with right-sided decompression of the lateral recess
and complete foraminotomy. The right leg pain resolved completely
postoperatively, but the patient complained of a new severe left leg
pain and no right leg pain; however, she complained of severe left
leg pain in the L3 distribution. Postoperative computed tomography
(CT) showed no obvious malpositioning of the screws but demon-
strated severe left L3–4 foraminal stenosis, as shown in Fig. 1,
which required revision surgery. During the surgery, we found that
the left L3 nerve root was flattened by an osteophyte from the su-
perior articular process of L4. We performed a full left L3–4 fora-
minotomy. Postoperatively, the patient’s left lower limb radiculopathy
was alleviated with no back symptoms.

Case 2
A 59-year-old woman with hypothyroidism and dyslipidemia
complained of back pain, radiculopathy of the right lower limb, and
neurogenic claudication. The patient had a history of L4–5 decom-
pression and fusion 5 years prior. The patient had no neurological
deficit. Radiography and MRI showed grade 2 degenerative spondy-
lolisthesis with spinal stenosis of L3–4. After conservative treatment
failed, the patient underwent L3–4 TLIF with right-sided decompres-
sion along with full L3–4 foraminotomy, and a TLIF cage was in-
serted from the right side. The patient reported no pain in the right
leg postoperatively. However, she complained of lower back and se-
vere left leg pain at the L3 level. Postoperative CT showed no
obvious malpositioning of the implants, adequate right L3–4 fora-
minotomy, full reduction of the L3–4 spondylolisthesis, and se-
vere left L3–4 foraminal stenosis due to a large osteophyte from
the L4 superior articular process of the L3–4 facet joint (Fig. 2).
The patient underwent revision surgery for a complete left L3–4 FIG. 2. Case 2. Immediate postoperative CT scan of the lumbar spine
foraminotomy. A significant improvement in the left L3 radiculop- showing subluxation of the superior facet of L4 into the foramen result-
ing in severe left L3–4 foraminal stenosis and left L3 radiculopathy.
athy was noted postoperatively.

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FIG. 3. Case 3. Postoperative CT scans of the lumbar spine showing
adequate left L4–5 decompression with an iatrogenic right L4–5 severe
foraminal stenosis.
sciatica. She had no neurological deficit, but the pain was so se-
vere that she was unable to walk for long distances and nonoper-
ative treatment measures had been ineffective. Preoperative
radiography and lumbar spine MRI showed degenerative L4–5
spondylolisthesis with local kyphosis at the segment. She under-
went L3–5 fusion with L4–5 decompression, left L4–5 foraminotomy
with TLIF insertion from the left side, as well as spondylolisthesis re-
duction and correction of local segmental kyphosis. She reported com-
plete alleviation of the left leg radiculopathy postoperatively; however,
she developed severe right leg radiculopathy. Postoperative CT scan of
the lumbar spine showed proper implant position and reduction in the
L4–5 spondylolisthesis with complete left L4–5 foramen decompression
with an iatrogenic right L4–5 foraminal stenosis with a large osteo-
phyte, as shown in Fig. 3. The patient underwent revision surgery to
achieve right L4–5 foraminotomy.
stenosis with facet subluxation, acute disc herniation, and epidural
hematoma.8 Surgeons must attend to patients’ concerns and investi-
gate according to these differentials. Postoperative MRI of the lumbar
spine would be helpful in assessing the possibility of acute disc hernia-
tion or epidural hematomas. However, MRI has limitations in viewing
the screw position and foraminal stenosis due to the presence of metal
artifacts, and early postoperative changes may result in another limita-
tion. A CT scan of the lumbar spine would ensure appropriate implant
position without any medial or inferior breech, along with proper as-
sessment of the foramina, which is best viewed in the sagittal views
(Fig. 1), and facilitates the identification of osteophytes from the supe-
rior articular process or facet subluxation, which led to foraminal steno-
sis. Insufficient disc removal and decompression would result in a
contralateral acute herniated disc. Additionally, unilateral cage insertion
may push the disc material to the contralateral side, leading to contra-
lateral disc herniation.7 A crucial goal of lumbar spine fusion surgery is
to restore adequate lordosis to prevent PI-LL mismatch, which could
lead surgeons to try and create a lordotic segment using lordotic
cages, contouring the rods into a hyperlordotic shape, or using com-
pression between the pedicle screws. However, this has been reported
to be a cause of iatrogenic foraminal stenosis.10 Two of our cases

Case 4
A 69-year-old male patient with a known history of diabetes mel-
litus and hypertension, along with a history of L4–5 decompression
and TLIF 2 years prior, presented with worsening back pain and
neurogenic claudication, and had no neurological deficits. Preopera-
tive radiological investigations showed solid fusion of the L4–5 with
loss of lordosis at that segment. Additionally, there were degenera-
tive changes with lithiasis of the adjacent levels L2–3 and L3–4
with severe L3–4 lumbar spinal stenosis (Fig. 4). After conservative
management had failed, surgery was performed. Surgical interven-
tion with extension of fusion to L2, decompression, and TLIF at the
L3–4 levels were performed. However, the surgeon anticipated the
need for increasing lordosis to compensate for the loss of segmen-
tal lordosis at the L4–5 level, and bilateral prophylactic L3–4 fora-
minotomy was performed to prevent iatrogenic foraminal stenosis at
the adjacent level, as shown in Fig. 5. The patient did well, and the
index symptoms resolved completely.

Discussion
Observations
Acute postoperative contralateral radiculopathy has been reported
as a complication following lumbar spine fusion surgery for degenera- FIG. 4. Case 4. Sagittal T2-weighted MRI of the lumbar spine showing
L4–5 decompression with L3–4 adjacent level disease with lumbar spi-
tive conditions, with an estimated incidence of 2.5–5.3%.7,9 Its causes
nal stenosis.
are variable, including screw malposition and iatrogenic foraminal

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FIG. 5. Case 4. Postoperative scoliosis series radiographs, anteropos-
terior and lateral views, showing correction of the coronal deformity and
restoration of the adequate lumbar spine lordosis with L2–5 fusion and
L3–4 TLIF. Note the full bilateral L3–4 foraminotomy.
presented were revision surgeries to treat adjacent segment disease
(ASD), and complete foraminotomies were performed on the side of
the index radiculopathy. The pitfall was creating segmental lordosis at
the fused segment to restore regional balance and prevent further
ASD, missing the fact that the contralateral foramen was at risk of iat-
rogenic stenosis, eventually requiring reoperation and contralateral
complete foraminotomy. Another proposed mechanism of iatrogenic fo-
raminal stenosis is the use of a unilateral TLIF cage, resulting in an in-
crease in foraminal height at the ipsilateral side and compression of
the contralateral foramen.3,6,10 Such a mechanism has been observed,
especially in cases of ipsilaterally placed cages. Therefore, it is advised
to position the cage in the middle or contralateral side of the interverte-
bral space to increase contralateral foraminal height and create local
scoliosis at the segment.10 One possible advantage of transverse
cages (LLIF) compared with TLIF cages is the achievement of indirect
contralateral foramen decompression rather than risking iatrogenic fo-
raminal stenosis.10,11 Theoretically, prophylactic foraminotomy on the
asymptomatic side is the most effective way to prevent such complica-
tions. Our protocol is to perform prophylactic foraminotomy in revision
for ASD (Fig. 5) in cases where we anticipate significant changes in
the LL and in cases with spondylolisthesis that require reduction.
Lessons
Iatrogenic foraminal stenosis of the lumbar spine is not uncom-
mon; careful planning and middle intervertebral space cage posi-
tioning are needed to prevent such a complication postoperatively.
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Disclosures
The authors report no conflict of interest concerning the materials or
methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Aldakhil, Konbaz, Alhelal, Aleissa. Acquisition of
data: Aldakhil, Alhelal, Bourghli, Aleissa. Analysis and interpretation of data:
Aldakhil, Ateeq. Drafting of the article: Aldakhil, Konbaz, Alhelal, Bourghli,
Ateeq. Critically revising the article: Aldakhil, Konbaz, Alhelal, Ateeq, Aleissa.
Reviewed submitted version of the manuscript: Aldakhil. Approved the final
version of the manuscript on behalf of all authors: Aldakhil. Statistical
analysis: Aldakhil, Bourghli. Administrative/technical/material support:
Aldakhil, Abalkhail. Study supervision: Aldakhil, Konbaz, Alhelal, Ateeq.
Correspondence
Sahar Aldakhil: King Abdulaziz Medical City, Central Region, National
Guard Health Affairs, Riyadh, Saudi Arabia. saharaldakhill@gmail.com.
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