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21-DECEMBER-2008  ZAYED MUHAMED AL-HALAYQEH  43 YEARS  HUGE RECURRENT PLD L4-5 LEFT SIDE.

Anamnesis:

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The patient came to the clinic 01-November-2008 complaining of LBP and left sciatica which persisted after performing discectomy L4-5  15-July-2008 elsewhere.

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On examination: the patient  has exaggerated scoliotic stance. SLRS was 85 degrees both sides. He had weak dorsiflexion left foot 4/5. Hypalgesia left L5 territory.

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MRI of the lumbar spine with MRMyelography was performed 02-December-2008 showing huge recurrent disc L4-5 with left downward migration.

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Using image-intensifier, the L4-5 level was identified and drilling of the upper left corner of the bony defect was performed. There was a lot of adhesion and the disc space was reached lateral to the left L5 root axilla. Cleaning of L4-5 was performed. after what the downward migrating piece was pushed to the disc space and removed in one block. There was a lot of adhesion around the root and trying to minimize the scar was achieved. Inspection of the dura anterior to the axilla could show a tiny dural defect less than 0.5 mm with intact arachnoid with no CSF leak. It was coagulated by bipolar to shrink and seal it.  Routine closure of the wound with water-tight multilayer stitching to prevent possible postoperative CSF leak.

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Smooth postoperative recovery and the power of left foot normalized.


Comments

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Recurrence still a dilemma, which needs proper solution in lumbar disc surgery. Key-hole surgery will provide higher recurrence rate and the patient will suffer clinically after surgery.

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The expected recurrence rate in this case is still around the average, because the disc space height still not shallow.

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In case of recurrence and adhesions, it is mandatory to look for dural defects and tears, so as to manage them properly.

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