Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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27-APRIL-2010 AMMAR ALI NAJY 40 YEARS
HUGE EXTRUDED DISC L4-5 WITH UPWARD MIGRATION BOTH SIDES MORE TO THE
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to the clinic 20-April-2010 complaining of
LBP with bilateral sciatica more to the left for
3 years. Exacerbation of LBP the last 45 days
with sciatica and numbness of both feet.
performed 11-April-2010 showed very huge
extruded disc L4-5 with upward migration both sides
more the right.
On examination: the
patient is limping with exaggerated scoliotic
stance with SLRS 20 degrees in the right and 5
degrees in the left. Planterflexion both feet 4/5
and dorsiflexion is 3/5.
Bilateral flavotomy and partial laminectomy L4
and upper edge of L5 was performed. Foraminotomy
of right L5 root was achieved. It was
noticeable, that there was CSF leak coming from
the corner of the right L5 root. The patient was
repositioned, so as to stop CSF leak and the
very huge extrusion was removed from the right
side 20 mm above the axilla and it was
separately migrating upward. Bilateral cleaning
of the disc of L4-5 was achieved. Inspection of
the right L5 root showed that its dural wall was
severely damaged at several places, that simple
repair is impossible. This finding was not
related to surgical trauma. It was due to severe
compression of the root by the extruded disc.
CSF came after flavotomy, when the compression
upon the root was eliminated. The epidural fat
was pathologically firm at these areas, that it
was possible to stitch it around the durally
damaged root. A piece of muscle was taken and
the root and the epidural fat were covered. This
was aided with surgicele. The patient was put in
position with the head in high position and
Valsalva maneuver was applied. No CSF leak was
coming from the direction of the root, nor from
the disc space in the left side. Another
wide-sheeted surgicele was put to cover all the
dural surfaces. Water-tight closure of the
The patient took 4 hours to awake from
aneasthesia. After interrogating the wife she
told that he has some sort of sleep apnea, for
what he was kept in the ICU for another 4 hours.
The patient then was transferred to the ward.
The power of both feet normalized.
The patient has very
huge extrusion that could cause dural tears to
the different neural structures. This could be
obscured before surgery due to presence of
compressed anatomical structures and becoming
evident during decompression.
The presence of root dural
tear before surgery can be aided with the
presence of thickened epidural tissues in that
point, which could be used to engulf the
Sleep apnea is becoming more
noticeable and interfering with many events as
in this case. The delayed recovery was
attributed to sleep apnea.
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 .