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09-FEBRUARY-2009  SAADIYEH HASAN AWWAD  48 YEARS  HUGE CENTRAL EXTRUDED DISC L4-5.

Anamnesis:

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The patient came to the clinic 11-October-2006 complaining of left sciatica for 10 days with scoliotic stance and weak dorsiflexion left foot 4/5. Investigations were requested, but she disappeared.

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The patient then came 27-August-2008 complaining of LBP and left sciatica and MRI lumbar spine performed 22-September-2008 showing extruded disc L4-5 more to left. She was advised to undergo conservative treatment and in case of not improving, then to consider surgery.

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The patient then came 02-February-2009 with deterioration of her left sciatica and inability to raise her right leg with weak dorsiflexion both feet 4/5.

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MRI lumbar spine performed 08-February-2009 showed very huge extruded disc L4-5 with central localization, resulting in secondary lumbar canal stenosis L4-5.

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On examination: the patient is limping with scoliotic stance. SLRS was limited to 0 degrees in the right and 90 degrees in the left  with absent AJ left side.

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Bilateral foraminotomy of L5 roots and bilateral cleaning of the extrusion. It was performed lateral to the axilla from the left and subaxillary from the right. Meticulous cleaning of the disc space of L4-5 was achieved. Inspection of the transparent dura at L4-5 level showed a tiny microscopic pin-point CSF leak, which was coagulated first, but the CSF continued to flow, for what 6 zero nylon was used to close the tear in one stitch. Check for CSF leak was negative. Routine closure of the wound.

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Smooth postoperative recovery with normalization of the power both feet.

Comments

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The patient has wide defect of the annulus fibrosis and the disc space is not shallow, for what the estimated recurrence rate is around 7%.

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The dura was very thin, that spontaneous CSF leak took place from the thinnest point. It was managed accordingly.

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