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09-AUGUST-2008  MUHAMED FUAD HARB  53 YEARS LCS L4-5 WITH CENTRAL EXTRUDED DISC L4-5 WITH RIGHT L5 ROOT COMPRESSION.

Anamnesis:

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The patient came to the clinic 07-August-2008 complaining of LBP and right sciatica for one month with exacerbation the last 5 days. The patient is insulin-dependent diabetic for 14 years and known hypertensive for 7 years. The patient underwent discectomy for L5-S1 15 years ago.

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MRI done 06-August-2008 showed residual after discectomy L5-S1 without recurrence and LCS L4-5 with huge central disc L4-5 with compression of the right L5 root.

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On examination: the patient has exaggerated scoliotic stance, limping with SLRS 40 degrees with pain in the right. There is weak dorsiflexion both feet -4/5 and mild weak planterflexion right foot with numbness both right L5 and S1 territories. He has OA. both knees.

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Laminectomy of L4 and the remnant of L5 was performed. Bilateral foraminotomy of both L5 roots was performed. Inspection the right L5 root revealed an extrusion compressing the root below the disc space, which was removed subsequently. Inspection the left L5 root revealed extrusion of the disc material, for what bilateral cleaning of the disc space L4-5 was performed.

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

Comments

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The patient had LCS L4-5 with evident compression of the right L5 root by extrusion. During surgery, inspection of the left L5 root revealed another extrusion for what bilateral intradiscal cleaning was performed.

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The estimated recurrence rate in this case is around the average, because the disc space height still not shallow.

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