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22-SEPTEMBER-2008  KHAWLA ABDALLAH SAEED  44 YEARS  EXTRUDED DISC L4-5 WITH RIGHT DOWNWARD MIGRATION.

Anamnesis:

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The patient came to the clinic 20-September-2008 complaining of LBP for 18 years with right sciatica. Exacerbation the last two months of the right sciatica.

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MRI performed 17-September-2008 showed extruded disc of L4-5 with right downward migration and complete occlusion of the right foramen.

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On examination: the patient in agonizing pain. Limping with scoliotic stance  with SLRS 45 degrees with pain right side. She had almost drop right foot and weak planterflexion left foot 4/5.

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The patient is a known diabetic and hypertensive  with elements of bronchial asthma.

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Right hemiflavotomy of L4-5 was done and foraminotomy of right L5 root was achieved.  The extruded with down migrating piece was removed in several fragments. Considering that the disc space still high and the annulus fibrosis is not hard and there is defect under the annulus, it was decided to clean the L4-5 disc space meticulously from the right side.

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The defect of the annulus fibrosis was wide, for what further cleaning was performed.

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Routine closure of the wound and smooth postoperative recovery.

Comments

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The patient had complete obliteration of the right L4-5 foramen with severe compression of the left L5 root. This must be resolved by surgery.

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The estimated recurrence in this case is around the average -7%, because the disc height is not shallow. Coagulation of the defect of the annulus fibrosis  decrease the dimensions of the defect, which theoretically could lead to lower the estimated postoperative recurrence.

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The patient having diabetes mellitus, for what during surgery cutting monopolar was avoided , instead using blade No 11 for bony dissection to minimize thermal injury to the soft tissues, to decrease the incidence of postoperative infection.

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