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03-NOVEMBER-2008  BAKER MAHMOUD AL-MADY  42 YEARS  HUGE EXTRUDED DISC L5-S1 WITH RIGHT DOWNWARD MIGRATION.

Anamnesis:

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The patient came to the clinic 21-October-2003 complaining of LBP for 2 years with intermittent course.  Right sciatica for 1 year.

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MRI lumbar spine performed 19-October-2003 showed wide-based extrusion of L5-S1 more to the right.

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On examination at that time: SLRS was 50 degrees in the right with pain  with weak dorsiflexion right foot  4/5. The patient was advised to undergo conservative treatment.

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The patient then came 20-October-2008 with exacerbation of LBP and right sciatica the last 7 months. MRI performed 04-March-2008 showed small extrusion of L5-S1 right side. one week ago after coughing the patient got an agonizing sciatica and start to limp.

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On examination: the patient is limping with exaggerated scoliotic stance, with SLRS 15 degrees in right side with pain and weak dorsi and planterflexion right foot -4/5.

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MRI lumbar spine was performed 21-October-2008 showing huge extruded disc L5-S1 with right downward migration.

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Partial flavotomy L5-S1 right side with foraminotomy right S1 root was performed. The new downward migrating disc material was removed lateral to the axilla. The old disc martial also was compressing the root, for what removal of the calcified annulus fibrosis with the hard disc material was removed to achieve proper decompression. Meticulous cleaning of the disc space was done from the right.

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Smooth recovery with prompt improvement of the power of the right foot.

Comments

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The patient had several surges of pain and surgery was decided only when the extrusion got huge amount. If the patient was operated upon during the early period , he will not feel the benefits of surgery, in the contrary he could have worse post-surgical outcome.

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The expected recurrence rate in this case is around the average, because the disc space height is not shallow and the annulus fibrosis defect is relatively large after removing the calcified annulus fibrosis and the old hard extrusion.

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