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08-JULY-2008  MUSA MUHAMED AL-SURAIKY  47 YEARS  CONDITION AFTER FIVE SURGERIES FOR RECURRENT PLD L4-5 RIGHT SIDE.

Anamnesis:

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The patient came to the clinic 04-December-2005 complaining of LBP and right sciatica with clinical manifestations of cauda equina syndrome after performed surgery for PLD L4-5 22-September-2005 elsewhere.

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MRI of the lumbar spine performed 15-September-2005 before surgery showed extruded disc L4-5 right side. MRI performed 30-November-2005 showing recurrence of the disc with bigger extrusion. He was operated 3 years ago for the same disc at the same level and side.

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On examination at that time: the patient was limping with scoliotic stance. SLRS was 20 degrees in the right and 30 degrees in the left with pain. There was weak dorsi and planterflexion right foot  3/5.

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The patient was advised to undergo another surgery and he came 21-June-2008, after performing three further surgeries for the same recurrence by another two neurosurgeons elsewhere.

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MRI of the lumbar spine performed 10-February-2008, showing still having recurrence at the same level with total deformity of the right L4-5 facet joint.

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On examination: the patient still in agonizing pain with scoliotic stance  with SLRS 30 degrees in the right and 40 degrees in the left with pain. He had weak dorsi and planterflexion both feet more the right.

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The patient was sent for new MRI with CT-scan and dynamic X-ray studies of the lumbar spine.

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The patient then came 24-June-2008 with MRI confirming the recurrence and practically absent right L4-5 facet joint.

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The patient was advised to undergo surgery for the recurrence and to remove the flail fragments of the totally destroyed facet and to use MTF allograft to accelerate the fusion between L4-5. 

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Right L5 foraminotomy with bilateral flavotomy of the L4-5 level was achieved under visual control of image-intensifier. In the right side of the dural sac, there was a massive scar embedded with movable bone fragments, which were the remnants of the right L4-5 facet. All these structures were removed and the dura was inspected to be fee from these pain-generating elements.

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The extruded disc which was rubbery hard was removed and drilling of the disc space of L4-5 was done to reach the anterior part of the soft tissue material, which was removed subsequently.

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Through this tunnel, chips of MTF bone allograft  were pushed to fill the intradiscal cavity. They were inserted with impactor to have good resistance and to prevent backward slipping.

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The right L4 root and the L5 roots were exposed to visually eliminate all compressive elements.

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Routine closure of the wound and smooth postoperative recovery with normalization of the power of both feet.

Comments

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The patient underwent five surgeries for recurrent disc at L4-5. His problem now is multifaceted and the fragments of the lost right facet joints are movable and pain generating. The recurrence also compressing the nerve root.

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Going to such sixth surgery, the surgeon must resolve all the causative factors in pain and neurological deficit generating elements.

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The aim of such surgery is to achieve future fusion of L4 with L5 and freeing the running roots of all compressive and irritating elements.

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In this case the expected recurrence rate is zero.

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