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31-AUGUST-2010 AHMAD MIRSHED ALI AL-MANASRAH 49
YEARS EXTRUDED DISC L4-5 WITH LEFT FAR FORAMINAL OCCLUSION AND STENOSIS
L3-4.
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Anamnesis
The
patient came
to the clinic 18-February-2004 complaining of LBP
for 3 years with left sciatica. The patient
was treated conservatively. Then he came
31-March-2008 with same complaints with SLRS
left 85 degrees with no sensory of motor deficit
and was treated conservatively.
The patient then
came 22-August-2010 with exacerbation of the
left sciatica the last week with agonizing pain
and limping with exaggerated scoliotic stance.
MRI lumbar spine performed 06-December-2003
showed bulge L3-4 and L3-4. SLRS was 30 degrees
in the left with pain and weak dorsiflexion left
foot and hypalgesia left L5 and S1 root.
MRI lumbar spine
performed 25-August-2010 showing extruded disc
L4-5 with left foraminal occlusion and stenosis
of L3-4.
Laminectomy of L4
and partial of L3 and L5 with foraminotomy both
L4 and left L5 roots was done. All the stenotic
elements were eliminated and the the extruded
disc of L4-5 was removed from the left side and
left sided cleaning of L4-5 disc space was
performed. Inspection of the L3-4 disc disclosed
that it is better not to violate it.
Routine closure of
the wound and smooth postoperative recovery with
improvement of the power of the left foot and
disappearance of left sciatica.
Follow Up
The patient progressed CSF
leak in the second day after discharge, for what
he was rehospitalized and was kept for 72 hours
in complete bed rest with Mannitol 25 gm TID.
The forth day the patient was ambulating and the
fifth day was kept in Lazix and discharged
08-September-2010.
Comments
The estimated postoperative
recurrence rate in this case is around the
average because the disc space is still not
shallow.
The extruded disc and
stenosis must be resolved so as to resolve all
the patient problems over the years.
Inspection of the dura during
surgery revealed no tears or punctuate defects
in the dura. Despite this fact, the patient
progressed postoperative CSF leak. Interestingly
to mention, that the patients operated before
and after this case, had dural defects due to
severe compression and they were managed
accordingly without CSF leak. This case is a
demonstration that even in the absence of
apparent tears or dural wall defects, CSF leak
still can have place after surgery. Using
Valsalva maneuver and elevating the head at the
end of the surgery are of no help.
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .
