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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.tv

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acousticschwannoma.com
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Neuroanatomical Sites
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Neuroendocrinologiacl Site
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Neuro ICU Site
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Neurophysiological Sites
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Neuroradiological Sites
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NeuroSience Sites
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Neurovascular Sites
vascularneurosurgery.com
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Personal Sites
cns.clinic
cnsclinic.org
munirelias.com

Spine Surgery Sites
spine.surgery
spinesurgeries.org
spondylolisthesis.info
paraplegia.ws

Stem Cell Therapy Site
neurostemcell.com


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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. 

 

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[2005] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved