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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

 

AMEEN SHEHDEH BADY  23 YEARS  RESIDUAL AFTER 2 SURGERIES FOR TETHERED CORD WITH CONUS MEDULLARIS LIPOMA.

The patient came to the clinic 21-June-2004 complaining of micturition erection and defecation problems  and LBP for 6 years. MRI done 23-May-2004 showing a huge lipoma of conus medullaris with tethered cord. On examination: cauda equina syndrome with weak dorsiflexion both feet and planterflexion left foot. Hypalgesia and analgesia below S1 root. The patient was advised to undergo surgery, which was performed elsewhere.

The patient came 31-October-2004 after performing surgery 19-September-2004 with same neurological status without improvement. He had no histological data reflecting the nature of the mass. He was sent for MRI, which showed the same picture as before without any changes. The patient was advised for redo and he disappeared.

The patient then came 29-June-2005 telling that he performed surgery elsewhere 15-January-2005. Decompression of the cystic fluidy mass without histological verification. MRI performed 12-June-2005 showed small residual of the mass, which still at the same level behind the L3 level. The patient telling that he regained nothing from surgery and the neurological evaluation was the same.

The patient then came 27-August-2006 claiming that, he progressed further deterioration  and he was sent another time for MRI investigation, which confirmed the presence of tethering and persistence of the cystic component at the same level. Laminectomy of L2-3 was noticed.

Laminectomy of L4 and 5 with uppermost of the sacrum was done with refreshment of the dura over L2 and 3 levels. Using electrophysiological monitoring, the tethered cord was identified  and separated from the running roots and bisected at the level of the sacrum. Immediately the cord jumped 20 mm upward. The scarous dura over the operated site was followed and opened from the left border, reaching the normal spinal cord proximal to the lesion. The adherent spinal cord to the dura was dissected sharp off the dura and to my surprise no stitches were noted in the area of surgery. After total myelolysis and neurolysis the spinal cord regained relaxed position and inspection for presence of a mass was negative. After retrospective analysis of the MRI data and the operative field, it became clear that the cystic mass was just and adherent neural structures stuck to the dura.

Water-tight closure of the dura and routine closure of the wound.

Comments:

1. Since tethering of the cord was his primary problem, it was logical to resolve the problem from the start. About his neurological recovery , time will give the answer and performing this kind of surgery, without using electrophysiological monitoring could lead to neurological deterioration.


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved