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Dr. Ali Al-Bayyati and Dr. Munir Elias

 
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

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15-NOVEMBER-2011  ZAHER ALI AL-QADUMEE  44 YEARS  HUGE EXTRUDED LEFT FAR LATERAL DISC L4-5 WITH FORAMINAL OCCLUSION.

Anamnesis

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The patient came to the emergency Shmaisani hospital 10-November-2011 complaining of LBP for 3 years  with exacerbation of LBP the last 4 days and agonizing left sciatica the last 3 days. The patient came in wheelchair and was unable to stand to evaluate Romberg or scoliotic stance. MRI lumbar spine of bad quality done showing extruded disc L4-5 and bulging L5-S1.

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On examination: SLRS was 70 degrees with pain in the right and 40 degrees with more pain in the left. There is weak dorsi and planterflexion left foot 3/5. There is hypalgesia of the left lower limb at D12 level. The deep reflexes are exaggerated in the right side and there is clonus of the right foot.

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The patient was sent for another MRI of the whole spine, which was done 11-November-2011 confirming the presence of PCD C3-4, 5-6 and C6-7 with malacia of the spinal cord at C5-6 level. These changes look old and the patient is not complaining of.  There is fresh PDD D7-8 right side and it was of soft consistency, slightly compressing the spinal cord.

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Left L5 root foraminotomy was performed and the left L4-5 lateral mass medial wall was drilled, so that greater exposure to the far-lateral space was achieved without violating the stability of the facet joint. The huge extrusion was pushing the left L5 root medially to the right. It was removed in several huge pieces. Left sided cleaning of the L4-5 disc space. The epidural fat was missing in the left side and around the root. After removal of the extrusion, the neural structures became lax.

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Routine closure of the wound.  Smooth postoperative recovery with improvement of the power of  the left foot.


 

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

 

Comments

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The patient had many problems, among them the most serious is the PLD L4-5, which is causing the agonizing pain. The PDD is soft one and it was decided to leave it for shrinking with time. The old changes in the cervical spine must be considered during positioning of the patient during surgery, so as to avoid positional injury to the spinal cord during surgery.

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The expected postoperative recurrence is still high around 7%, because the disc space still not shallow.

 


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