Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
neurosurgery.fr
The patient was seen by me 2 years
ago complaining of left sciatica with LBP. MRI showed
spondylolisthesis L5-S1. The patient was advised to undergo
conservative measures and his condition remained the same. The last
4 months, his condition deteriorated dramatically and he was unable
to perform his job as lawyer. He came to me with agonizing pain with
new MRI urging for surgery. It was explained to him the pros and
cons of the surgery. He came late in the night with severe sciatica
and almost drop left foot with weak planterflexion of the same foot
and hypalgesia of the left L5 territory. He underwent surgery the
next day. After skeletonization of the upper sacrum, L4 and L5, it
was noticeable that the L5 lamina is flail. Foraminotomy of left S1
root was done and with preservation of the flail lamina 45 mm length
polyaxial transpedicular screws were inserted at the level of L5
pedicles and 35mm length inserted to the sacrum. Distraction was
applied for the aid of reduction and a bridge was inserted between
the rods to achieve more secured fixation. Several control X-rays
with image-intensifier were performed. The left upper screw was a
little lateral, but inside the body of the L5. It was checked for
stability and it was rigid. Considering these data, and the presence
of bridge it was accepted.
Comments:
The patient continued to complain
of left sciatica and several times came to the clinic and several
control X-rays were performed beside the control CT-scan performed
after the operation. All were acceptable. The last time he was seen
after telephone call that he claim that he felt down and he was
asked to come with control X-ray, but he came without the control.
Later by telephone, he told me he is undergoing another surgery
in another hospital by orthopedic surgeon for dislodgment and
loosening of the construct. He underwent surgery by the orthopedic
surgeon 12-December-2005, and as I understood from the indirect
communications that the upper left screw was loose and a new
construct was inserted to make fusion between L4 and the sacrum
and the loose lamina was removed.
Conclusions:
1. Do not ever trust any construct
for perfect solution. They are all liable to loosening, fracturing
and slipping.
2. The Syntex and many constructs
lack locking mechanism, to prevent the transpedicular screw from
coming out after their insertion.
3. It is a bad idea to perform
fixation of spondylolisthesis by transpedicular screws using the
pathologic levels. It will be more reasonable to perform the fusion
in the healthy bony structures. Fusin of L5-S1 spondylolisthesis
must performed at L4 and the sacrum, to avoid the pathologic boney
structures.
4. All the loose bony elements
must be removed and bring all the involved roots under vision and
try to eliminate all the compressive elements. By doing this, the
surgeon will be sure that the neural structures are preserved and
transpedicular screws causing no harm to them.
5.Bone grafting is mandatory and
lumbosacral support for minimum for 4-5 months also is mandatory, to
wait the bony fusion, and to forget about the assurance of various
companies about the perfect constructs they provide.
Addendum:
The patient as mentioned is a
lawyer and he came back 17-January-2006 to the clinic asking for
compensation. His arguments were not scientific and claiming that
the other doctor told him, that the first construct was inserted
wrongly ( see the postoperative CT-scan to confirm that he and his
second doctor are lyres). Considering that he is a trouble maker he
was given 3000 JDs or 4300.00 USD to finish the headache which
he could cause. From this real-life scenario here the conclusions:
1. It is bad to see doctors with
low attitude, holding conflicting situation, misinforming the
patient about the previous treating doctor. For a note, this same
doctor I personally operated after him 8 times, and even he do not
know about that, because I urged the patients to hold conflicts in
case, if I am going to stitch his mistakes.
2. There is great gap in the
spiritual thinking of the neurosurgeon and the lawyer. The
neurosurgeon suffer more than the patient for even his pain and he
is trying his best to offer to resolve the problems, and there is a
feeling of gilt even if he did not made mistake, as in this case. In
the other hand, some lawyers are the product of wild jungle, where
the greedy and all aggressive colors of human behavior are molded
in there spirit. This huge gap make both sides, even cannot
understand the reaction of each other.
3. Think 1000 times before
treating a lawyer, and do not rush with decision, and take written
signature, that he accepts all the natural complications, which could
happen to him. At best avoid him, let him fool others.
4. It is hard to evaluate the
personality of the doctor, but I think, before accepting a student
for medical education, there must be an important item for studying
and testing the student to avoid from selection a personality not
fit for human service.
5. The doctor must be ready for
all negative situations in life and try to be patient with his
feelings, otherwise, MI will be an eminent squeals.
