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11-NOVEMBER-2008  AKRAM ABDEL-RAHEEM SULAYMAN  43 YEARS  CENTRAL EXTRUDED DISC L4-5 WITH LEFT UPWARD MIGRATION.

Anamnesis:

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The patient came to the clinic 20October-2008 complaining of LBP for 7 years.  Exacerbation of LBP with Left sciatica the last month with intermittent claudication when walking 100-150 meters.

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MRI lumbar spine performed 10-October-2008 showed huge extruded disc L4-5  central more to the left with upward migration.

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On examination: the patient is limping with exaggerated scoliotic stance, with SLRS 75 degrees in the right and 80 degrees in left side with pain and weak dorsiflexion left foot -4/5 and 4/5 right foot.

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The patient has bronchial asthma  and he was given prednisolone 20 mg twice daily for 10 days. He was told to stop it. The patient has also Gilbert's disease.

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Partial decompressive laminectomy of L4 and L5 was performed. Foraminotomy of left L5 root was achieved. Left L4-5 hemiflavotomy was done. The extruded disc L4-5 was attacked lateral to the left axilla. Meticulous cleaning of L4-5 was performed, trying during that, not to enlarge the defect in the annulus fibrosis. The root became lax. Routine closure of the wound.

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Smooth recovery with prompt improvement of the power of both feet.

Comments

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The patient had an extruded centrally located disc more to the left. It was causing secondary segmental canal stenosis. The extrusion was old and the clinical manifestations were a mixture of stenosis and radiculopathy. Both elements must be corrected during surgery.

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The estimated recurrence rate in this case is around 7% since the disc space height is still not shallow, despite the fact that the defect in the annulus fibrosis was minimal, in the hope to lower the estimated rate of recurrence.

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Gilbert's disease is a benign one but anesthesia must be considered to prevent liver drug interactions. At the same time bronchial asthma also must be taken into consideration.

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