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
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13-DECEMBER-2010 KALIMEH ABDEL-KAREEM HABIB 58
YEARS SPONDYLOLISTHESIS L4-5 WITH SEVERE SECONDARY STENOSIS.
Anamnesis
The patient
came to the clinic 09-December-2010 complaining
of LBP with bilateral sciatica, more the right
for 10 years, progressing with time. MRI lumbar
spine performed 26-May-2010 reported as having
LCS L4-5 and L5-S1. She was operated elsewhere
and she did not improve after surgery. MRI
lumbar spine repeated after surgery 26-June-2010
showed decompression of L2-3, 3-4 with the L4-5
and L5-S1 still the same.
On
examination: The patient is in pain,
limping with exaggerated scoliotic stance. The
patient cannot walk more than 20 meters. here is
weak dorsi and planterflexion both feet -4/5
with hypalgesia below the knees both legs. The
patient was also complaining of bilateral CTS,
more the right.
The
patient was sent for investigations, and MRI
performed 09-December-2010 showing
spondylolisthesis L4-5 II degree by Meyerding.
and severe LCS at this level with bulge L5-S1.
EMG confirmed the presence of severe compression
both median nerves more at the right wrist.
Decompressive laminectomy of L4and L5.
Foraminotomy both L5 roots. The disc space was
cleaned from both sides more from the left. The
spinous process and lateral masses of L4-5 were
mobile from the start of the operation.
TILF Leopard 7 mm height was inserted to
the disc space L4-5 from the left, aided with
Novabone. The space was aided with her own bone
harvested from the spinous processii.
Transpedicular polyaxial screws 5.5 mm X35 mm
was applied to the L4 pedicles. Transpedicular
screws polyaxial 6.5 mm X 40 mm were applied to
the L5 pedicles. All these steps were guided
with image-intensifier and checked by IOM ISIS
HighLine with transpedicular protocol. The roots
were responding to stimulation around 3-4 mA.
The screws were not responding to currents even
with more than 20 mA, which means that there is
no contact between the screws and running roots.
Two bended rods 45 mm length were inserted and
fixation achieved with slight compression. A
transverse connector 52 mm was applied to
stabilize the rods. MTF Cancellous bone chips 15
cc were inserted lateral to the rods.
Routine
closure of the wound. Smooth postoperative
recovery.
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Comments
The patient was operated
initially for the wrong diagnosis with the wrong
level.
The best option for this case is
trilateral fixation using the TILF and transpedicular
screws, after achieving good neural decompression.
IOM with dedicated transpedicular set
designed by Inomed is a mandatory part of surgery to
avoid neural injury complications.
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 .
