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19-MAY-2009  AZMY FUAD LUKASHA  53 YEARS  RIGHT FAR-LATERAL DISC PROTRUSION OF L4-5 WITH EXTRA-FORAMINAL UPWARD MIGRATION.

Anamnesis:

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The patient came to the clinic 16-December-2007 complaining of LBP for 10 years with right sciatica for 2 years. The last five days exacerbation of right sciatica.

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On examination: the patient is limping with exaggerated scoliotic stance with SLRS 0 degree in the right and 80 degrees in the left. There is weak dorsiflexion right foot 4/5.

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MRI lumbar spine performed 17-December-2007 showed right far-lateral extrusion L4-5 with foraminal occlusion.

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The patient was advised to continue conservative treatment in the hope of shrinkage of the extrusion.

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The patient came 01-March-2008 claiming that he got improvement and clinically he was also doing well.

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The patient sent for new MRI lumbar spine, which was done 02-March-2008 which showed regression with comparison with previous MRI.

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The patient then came 30-April-2009 complaining of escalation of the LBP with right sciatica after performing physical effort. On examination he had weak dorsiflexion right foot -4/5 with SLRS 60 degrees with pain.

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MRI lumbar spine done 30-April-2009 showing further extrusion of L4-5 to the same place over the old shrunken one. The patient was advised to continue in conservative treatment but he could not tolerate the pain and he came 17-May-2009 asking for surgery.

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Right hemiflavotomy of L45 was performed and using drilling, the facet was drilled, so that to reach the far-lateral area from the right. The big piece was migrating upward out of the foramen. It was removed in several pieces and cleaning of the shallow disc of L4-5 was performed from the right. Check for remnants at the extrusion site was negative and attempt to expose the laterally running right L4 root was not attempted to avoid unnecessary scar formation.

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

Comments

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The estimated recurrence rate in this case is now must be very minimal, because the disc space very shallow.

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The patient has far-lateral disc at L4-5 mostly out of the foramen. Attempts for conservative treatment succeed in 80% but in this case it did not work.

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The approach in this case is not standard and all the attempts were necessary to reach the extrusion and remove it, without causing destruction to the bony elements.

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