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Dr. Ali Al-Bayyati and Dr. Munir Elias

 
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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05-DECEMBER-2011  KHALAF FARES ATIYEH  53 YEARS  WIDE BASED EXTRUDED DISC L5-S1 MORE TO THE RIGHT AND LEFT SIDED SCIATICA.

Anamnesis

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The patient came to the clinic from Iraq 03-December-2011 complaining of LBP for 11 years with left sciatica for 2 years with numbness both feet the last 4 months, more to the left L5 territory. MRI lumbar spine of bad quality done 12-September-2011 showing bulge L4-5 and extruded disc L5-S1  more to the right.

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On examination, the patient now is not limping with exaggerated scoliotic stance. SLRS was 90 degrees in both sides. There is weak dorsiflexion both feet with no sensory deficit. The patient was complaining of a painful click when turning his spine.

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The patient was sent for new MRI and CT-scan of L3-S1 with dynamic LSS X-ray, which were done 04-December-2011 showing huge wide-based extrusion L5-S1 with right downward migration and compressing the right S1 root, but touching the left S1 root. There was no bone anomalies, nor spondylolisthesis nor instability.

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Partial bilateral flavotomy with preservation of the 90% of the layer over the dura to preserve the epidural fat. The extruded disc was removed first from the right side. The left S1 root was exposed. It was encapsulated with abnormal venous net, which was coagulated. Bilateral cleaning of L5-S1 disc space. Xylocain with diprofos was injected to the left sacro-iliac joint.

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Routine closure of the wound. Smooth postoperative recovery with improvement of the power of  the feet.


 

Please! wait for 3-5 min till the video start to load. It depends upon the internet connection.

Comments

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The patient has huge extruded disc and the major extrusion was in the right side, but he complained of left sciatica. It happens, that the severely compressed root is not generating pain, but the less compressed or mechanically irritated root is suffering as in our case.

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Comparing the two roots of S1, the left one was rich with thickened abnormal veins. It could be that, as the case in trigeminal neuralgia, the venous abnormalities could trigger pain, for what ablation of this venous abnormality was mandatory with simultaneous preservation of the epidural fat. This step was taken, because the major extrusion was in the right, but the patient was complaining from the left side. Even left sacroiliitis was ruled out before surgery, injection with diprofos was performed to the left SIJ.

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The estimated recurrence rate, still around 7% because the disc space still not shallow.


Reformatted CT-scan ruling out instability or pelvic bone pathologies.


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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 .

 

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