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20-MARCH-2010  JAMAL AWWAD AL-AWAMLEH  63 YEARS  PROGRESSIVE SEVERE LUMBAR CANAL STENOSIS  L4-5 WITH LATERAL RECESS SYNDROME MORE IN THE LEFT WITH BILATERAL EXTRUSION.

Anamnesis

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The patient came to the clinic 12-December-2009 complaining of LBP for 2 years. Exacerbation of LBP with right sciatica the last 2 months. He had micturiton problems for 3 years.

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MRI cervical spine performed 18-May-2009 showed PCD C7-D1 with dehydrated all disci. MRI lumbar spine showing dehydrated all disci with elements of lumbar canal stenosis at L4-5 more in the left side.

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The patient was limping with exaggerated scoliotic stance. SLRS was 20 degrees in the right with pain. There was hypalgesia right L5 and S1 with weak dorsiflexion right foot -4/5.

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MRI lumbar spine performed 22-December-2009 showed elements of lumbar canal stenosis of L4-5 with far-lateral extraforaminal extrusions more in the right.

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The patient was advised to undergo conservative treatment and he showed improvement after several weeks.

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The patient then came 08-March-2010 complaining of left sciatica for the last 8 days with progression of profound weakness of both legs with difficulty of walking in bended position.

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On examination: the patient is limping with exaggerated scoliotic stance. He has coldness with numbness both feet. SLRS was 60 degrees in the right and 80 degrees in the left with pain. He had hypalgesia of the lateral aspect of the left foreleg. Dorsiflexion of the right foot was 0/5 and 4/5 in the left  with planterflexion of the right foot 3/5 and 4/5 in the left. The pedis dorsalis and femoral pulses of both legs were preserved. The elements of cauda equina became more pronounced with escalation of defecation problems.

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MRI of the lumbar spine performed 10-March-2010  showing progression of the lumbar canal stenosis with complete obstruction of the canal at this level with lateral recess syndrome more in the left with MRA of the aorto-femural and arteries of both legs were normal. MRI of the brain performed 20-June-2009 showed small lacunar infarction of the left parietal lobe. Bone density scan done 20-January-2010 was normal.

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Decompressive laminectomy of L4,5 and partial of L3 with extended foraminotomy of both L5 roots. The ligamentum flavum was adherent to the dural sleeve due to old compression in the right side.  Inspection of the extruded disc of L4-5 revealed, that it was necessary to remove the extrusion from both sides and bilateral meticulous cleaning of L4-5 disc space was performed.

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Routine closure of the wound.

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Smooth postoperative recovery, and the power of both feet became better.


Comments

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Lumbar canal stenosis is a progressive disease and the sooner the compression is removed the better the outcome.

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When extrusion take place in the stenotic area, profound neurological deficits became evident in the clinical picture.

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During surgery, all the morphological problems must be taken into consideration and resolved accordingly.

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The expected recurrence rate in this case is below the 10% average, because the disc height is shallow and the disc space is nearly empty due to vacuum phenomena.

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