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11-JULY-2010  SAMEER MAHMOUD ABED AWAD  37 YEARS  RECURRENT PLD L4-5 LEFT SIDE.

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

 

Anamnesis

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The patient was admitted to Shmaisani hospital 09-July-2010 complaining of agonizing left sciatica and almost drop left foot.

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The patient was operated at UH 26-June-2010 for extruded disc L4-5 left side without improvement, in the contrary with clinical deterioration.

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MRI of the lumbar spine performed 09-July-2010 showing recurrence of L4-5 left side with complete occlusion of the foramen of left L5 root. Lab investigations ruled out the presence of infection.

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On examination: the patient in agonizing pain with left sided sciatica and inability to walk. There is drop left foot with weak planterflexion left foot 4/5. There is hypalgesia left L5 territory. SLRS was 5 degrees in the left with pain.

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The upper half of the wound was refreshed and the left upper corner of the L5 laminar defect was drilled out and the remnants of the ligamentum flavum  were removed. Scarolysis of the compressed left L5 root was done and foraminotomy of the left L5 root was performed. The extruded disc was removed lateral to the axilla in several pieces and meticulous cleaning of the L4-5 disc space was achieved. Inspection of the root and subaxillary region was done to rule out migrating fragments. The root was hanging free at the end of the operation.

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Routine closure of the wound and smooth postoperative recovery.

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The power of the left foot dramatically improved and the left sciatica disappeared.


Comments

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Recurrence of the lumbar disc can happen even immediately after turning of the patient from the operating table. It can happen even after 30 years after surgery.

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In my practice, it happened twice that in the recovery room, when the patient demonstrating that he has still agonizing sciatica without improvement of his neurological deficit, the patient was sent back to the operating room, and the wound was reopened to find a huge recurrence, which was removed accordingly. One of the patient even did not remember that he underwent 2 surgeries at the same time.

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It is wrong to consider recurrence as complication of lumbar disc surgery. It is part of the problem and it happens in 7-15% of cases according to several parameters.

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The surgeon must explain to the patient about this possibility to avoid future postoperative conflicts.

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Using PEEK Satellite sphere of Medtronic was abandoned by us because it caused severe reactionary changes of the adjacent vertebral bodies due to pressure necrosis of both endplates.

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The patient still have the possibility of another recurrence, because the disc space still not shallow. The estimated recurrence in this case still ranking around 7%.


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