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The patient was admitted to
Shmaisani hospital 08-April-2009 with history of
gun shoot 20-March-2009 with paraplegia below L3
more dense in the left and cauda equina syndrome
with loss of sphenteric functions and sensation.
The patient progressed pulmonary embolism 2 days
before transfer from KHMC which was treated
accordingly. |
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On examination: there is
slight movement of right L5 territory with
complete paralysis of all nerve roots below L3. |
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There was rupture of the
medial collateral ligament of the right knee and
posterior crociate ligament which was repaired
14-April-2009. |
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CT-scan of the L2-4 showed
the shrapnels inside the cauda equina behind L2
and 3 levels. |
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Laminectomy of L2 and 3 was
performed. The patient due to anticoagulation
with clexan which was stopped three days ago,
had gross bleeding tendency, that the epidural
fat was oozing all the time. Using
image-intensifier the big metallic fragment was
explored which partially extradural and
partially intradural and was removed fro the
left side. Inspection of the dural wall
showed that it had many tears and there were
only two rootlets avulsed as vision permit. The
dural defect was extended inferior and the other
fragment was looked for. Using image-intensifier
this shrapnel was setting between the rootlets,
which were adherent. It was necessary to split
the rootlets so as to reach the shrapnel and to
remove it so that not to perform surgical trauma
to these anatomically preserved rootlets. All
the stage of the operation were performed using
IOM ISIS and the DNS did not show any response
even with high currents reaching up to 10 mA. |
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Most of the rootlets were
anatomically preserved but swollen and contused.
It was impossible to perform closure of the
dura, for what Tachyseal was used to cover the
area and aided with surgicel over it.
Water-tight closure of muscles. |
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Smooth postoperative recovery
with slight deterioration of the already
compromised right L5 root. |
