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24-NOVEMBER-2008  RAED AHMAD AL-ZUUBY  32 YEARS  SECOND RECURRENT PLD L4-5 RIGHT SIDE.

Anamnesis:

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The patient came to the clinic 01-November-2008 complaining of right sciatica during walking for one week. The patient was operated by me 03-August-2008 for recurrent PLD L4-5.

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On examination: the patient  still having mild scoliotic stance  with SLRS  65 degrees in the right with hypalgesia right L5 root. The power of the feet was normal. The patient was sent for investigations.

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MRI lumbar spine performed 05-November-2008 showed another huge recurrence of L4-5.

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The old incision was refreshed and the right upper corner of the L4 lamina was skeletonized. Without removing or drilling any bony elements, the disc space was reached and slight cleaning of the disc space was performed, trying during that to release the running L4 root medially. After releasing the root medially, it was possible to remove the extruded fragments of the annulus fibrosis in several pieces. Further cleaning of the L4-5 disc space was performed. The running root became lax the disc space cavity became empty under visual control.

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Smooth recovery with disappearance of the right sciatica.


Comments

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The patient in the previous surgery had wide defect in the annulus fibrosis. This fact led to higher expectation for the second recurrence, since the disc space height was not shallow at that time. Now the disc space became shallower, for what after performing the third operation, the expected recurrence rate in this case became lower than 7%.

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There is a small group of patients, which show some strange phenomenon, that the disc material grow after surgery. Despite the meticulous cleaning of the disc material inside the disc space, new disc material grow and these patients are liable for 2-3-4-5 recurrence.

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Theoretically speaking, a cadaver study must be performed to know the average weight of the disc of L2-3, 3-4, 4-5 and L5-S1. Also to have information about the weight of the annulus fibrosis. We tried several times to weight the mass of the removed disc material, but there is no reference to judge the percent of removal.

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MRI studies must be refined, so as to achieve more information about the intradiscal architecture of the disc material and the degree of fragmentation and presence of any associated inflammatory or other processes. This can give some keys to better understand the problem and take appropriate measures.

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Usually the recurrence most of the time is the layers of the slipped fragments of annulus fibrosis material as in this case.

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The actual recurrence rate is around 30%, but only 7% need surgery. As a routine all the patients, how come to the clinic after one month complaining of recurrence of any signs, new MRI with contrast is performed even if they are neurologically free.

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As noticed in all surgeries for discectomy, foraminotomy is performed. This step provide less pain and usually no neurological deficit in case of recurrence. This step also has the advantage to release the root before performing the removal of the extrusion and give the surgeon the ability, whether to remove the disc subaxillary or lateral to the axilla or both.

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At this stage of my knowledge, only the disc space height and the dimensions of the annulus fibrosis defect, play the most determinant factors in the recurrence rate.

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Back Up!

Notice: Not all operative activities can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also escaped from the plan .

     

  

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