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19-MAY-2009  ABDEL-KAREEM ABDALLAH AL-BASHA  67 YEARS  CONDITION AFTER TREATED DISCITIS OF L3-4, L4-5 AND L5-S1 WITH RECURRENCE AT L4-5 LEFT SIDE.

Anamnesis:

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The patient was operated by other neurosurgeon 02-September-2008 for left sciatica. The patient came to the clinic 25-March-2009 with clinical deterioration the last three weeks. The patient using crutches for 6 years for complicated fracture of the right lower limb with infection.

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On examination: the patient could not be evaluated for Romberg position and SLRS was zero in the right due to old Polio and 60 degrees with pain in the left. The patient had weak all muscles right upper limb 4/5 and extension and left triceps muscle 4/5. He had almost drop right foot with weak planterflexion right foot and dorsiflexion left foot with abduction both knees 3/5 and adduction of the knees 4/5.

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MRI lumbar spine, which was done 14-December-2008 which showed stenosis at L3-4 and L4-5 with ganglion from the left L4-5 facet joint compressing the left L5 root.

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The patient sent for another MR investigations, which confirmed the presence of malacia of the spinal cord at C5-6-7 level without apparent compression. He had scattered old infarctions both cerebral hemispheres.

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The patient was treated conservatively and he showed improvement and came to the clinic 29-April-2009 with improvement of both upper limbs and the left lower limb with regression of the left sciatica. The patient had severe OA both knees and he was sent for orthopedic consultation.

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The patient then came 12-May-2009 with agonizing left sciatica for 4 days with numbness of the left foot.

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On examination SLRS was zero in the right (Polio) and 30 degrees in the left with pain. He had dramatic deterioration of the power of the left foot. MRI lumbar spine performed 15-May-2009 showed recurrence of L4-5 left side with severe compression of the left L5 root with huge cyst below the axilla of L5 root reaching the level of L5-S1.

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The wound was refreshed and the right corner of L4-5 was skeletonized. Foraminotomy of left L5 root was achieved and laminectomy of L4 was performed. The old gangliotic deformity of the left L4-5 facet was removed and the extruded disc of L4-5 was removed lateral to the axilla. The nerve was pushed anteriorly. Inspection of the axilla from the underside showed fluidic cyst compressible and mostly due to old localized infection and with CSF content. All attempts were directed to avoid its rupture. The root was lax and meticulous cleaning of the inflamed disc material of L4-5 was achieved.

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Smooth postoperative recovery with disappearance of left sciatica.

Comments

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This case is a complicated case and it is hard to take decision when to operate and when to keep in conservative treatment. The patient had discitis and the loculation which appeared later is the result of such infection.

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