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14-JUNE-2009  ABDALLAH MUHAMED HASAN AL-HORANY  58 YEARS  PLD L3-4 WITH LEFT FORAMINAL COMPRESSION AND RIGHT DOWNWARD MIGRATION.

Anamnesis:

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The patient was operated by me 18-November-2008 for lumbar canal stenosis L3-4 and L4-5. The patient did well, but he came back 05-May-2009 to the clinic complaining of LBP and left sciatica for 2 months. The patient is a known diabetic with 90 units of humilin daily with glucophage 850 mg twice daily.

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On examination: the patient was limping with weak dorsiflexion left foot 4/5 and hypalgesia right L5 territory.

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MRI lumbar spine, which was done 04-June-2009 showed extruded disc L3-4 with left foraminal occlusion and right downward migration.

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Using image-intensifier, the L3-4 level was identified. Neurolysis of left L4 root was performed. The extruded disc was adherent to the root and there was a small tear in the root. The extruded disc was removed from the left side and meticulous cleaning of the disc space was performed from the left. The dural defect was covered with 2 layers of muscle and water-tight cleaning of the wound was achieved.

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Smooth postoperative recovery with improvement of the power of the left foot.

Comments

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The patient was operated first for lumbar canal stenosis 7 months ago. During that time there was no extrusion of L3-4.

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The tear in the dura was seen despite the fact that all precautions were undertaken to avoid that. The cause of the tear mostly is due to the friction with the small pituitaries during disc removal.

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Closure of the defect was impossible, because there were only scars. The only solution was tamponading the defect with 2 layers of muscle filling the defects and sealing the dura.

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