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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

 

 

17-OCTOBER-2006  BASSAM AHMAD MAHMOOD  48 YEARS  VERY HUGE EXTRUSION L3-4 DISC WITH BILATERAL DOWNWARD MIGRATION.

The patient came to the clinic 12-October-2006  complaining of LBP for 13 years with exacerbation the last 5 months with inability to set and walk the last month. He had an exaggerated scoliotic stance and it was difficult to examine the patient in supine position.

On examination: SLRS was 30 degrees in the right and 60 degrees in the left. KJ and AJ were absent in the right side with almost drop right foot and hypalgesia of the right L5 territory. The patient was sent to perform MRI lumbar spine, which showed a very huge disc L3-4 with bilateral downward migration more in the right.

After identifying the level under image-intensifier, bilateral foraminotomy L3-4 and flavotomy were performed. The dura was very thin, that even with great precautions there were two minor defects in the dura, that through one of them the roots came out and they were left at their place, because there is no space to push them back.  The extruded disc was hard in consistency and it was wise to attack it from the left lateral to the L4 axilla. Piece meal removal was performed to prevent injury to the root.  The disc space was cleaned meticulously from both sides and the osteophyte in the left side was removed. After removal of the compressive elements the CSF started to come out and the patient was repositioned in Trendelinburg position to minimize leakage. After inspection of the foramina and assurance that no disc fragments left behind, the bulged roots were easily repositioned back intradurally  and the dural defect was closed using nylon 6 zero water-tightly.  The another defect was so small that coagulation of the defect was sufficient to close it.  The patient was repositioned with the head over the place of surgery and Valsalva maneuver was performed to check for CSF leak. No CSF leak. Routine closure of the wound and smooth postoperative recovery.  

Comments:

1. In this case, the opposite situation in comparison to the yesterday performed surgery, it was necessary to perform bilateral cleaning with osteophytectomy. In this case meticulous cleaning of the disc space was necessary from both sides  to minimize the recurrence rate.

2. The patient came in bad clinical and morphological situation with lengthy delay in performing surgery. All these factors minimize the recovery rate of the patient. This is the rule, and time will show if he is an exception.

 

 


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