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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

 

 

11-DECEMBER-2006  YASER MANASRAH  35 YEARS  PLD L2-3 WITH SEGMENTAL STENOSIS AND DROP LEFT FOOT.

The patient came to the clinic 05-November-2006  complaining of LBP for 25 years. The last 6 months got exacerbation with left sciatica. MRI performed 17-June-2006 showed bulging disc L2-3 and L5-S1.

On examination: the patient is limping with exaggerated scoliotic stance, walking with difficulty. SLRS was 45 degrees in the right and 30 degrees in the left with weak dorsiflexion all toes left foot. The patient was advised to perform another MRI, which was done 06-November-2006, showing PLD L2-3 with upward migration. The patient when he came the second visit with the MR investigation, claimed that he improve, for what he was advised for conservative treatment.

The patient then came 08-December-2006, claiming that his condition dramatically deteriorate, with urgency and frequency the last 2 weeks. The patient then was sent for the third MRI of the lumbar spine, which confirmed the presence of severe stenosis with disc extrusion at L2-3.

Laminectomy of L2 and partial of L3 was performed and the compression was so severe, that there were tears in the right side of the dura with the roots coming out from them. These tears were not iatrogenic, because meticulous attention was paid for that, before the discovery of the 3 minitears. There was no covering epidural fat tissue in the whole area. The bulging through the tears roots, left untouched. Bilateral cleaning of the L2-3 disc space was performed and the sequestration was removed and all the compressing elements were cleaned, after what it was possible to push the roots back through their tears.  Using 6 zero nylon, the tears were water-tightly repaired and check for leakage with turning the head up with Valsalva maneuver  was negative.

Smooth postoperative recover and the power in both feet normalized.

Comments:

1.  Lumbar canal stenosis with presence of extrusion, both together, enforce for surgery, as in this case. Conservative treatment failed and surgery was the only solution for his problem.

2.  When there is severe stenosis with severe compression, the dura can be torn before surgery and these tears becoming evident during the surgery. Attempt to push the roots inside the compressed dura only provoke mechanical trauma to them. It is logical to leave them and decompress the area, after what, they some times return back simultaneously.

3. The presence of tears with bulging roots without CSF leak, indicate that there is severe compression, which must be resolved before attempting to push back the roots.

4.  The disc material outside and inside the disc space was inflammatory in appearance and part of the ligamentum flavum and posterior longitudinal ligament were swollen, indicating, that some inflammatory process having place. In the future, some certain investigations must be done to have more clear picture about such a case.

 

 


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved