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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 RIGHT.

Please! wait for 3-5 min till the video start to load. It depends upon the internet connection.

 


 

Anamnesis

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The patient came 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.

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MRI lumbar spine performed 11-April-2010 showed very huge extruded disc L4-5 with upward migration both sides more the right.

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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.

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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 wound.

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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.

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The power of both feet normalized.


Comments

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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.

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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 deformed root.

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Sleep apnea is becoming more noticeable and interfering with many events as in this case. The delayed recovery was attributed to sleep apnea.


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Notice: Head injuries and very urgent surgeries are also escaped from the plan .

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