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29-NOVEMBER-2008  IFTIKHAR TAWFEEQ ABDEEN  60 YEARS  PLD L4-5 MORE TO RIGHT WITH SECONDARY CANAL STENOSIS.

Anamnesis:

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The patient came to the clinic 01-August-2005 complaining of LBP for 9 years with right sciatica for the last 2 years. MRI lumbar spine performed 05-November-2003 showed small PLD L3-4, 4-5 and L5-S1. The patient at that time had scoliotic stance with SLRS 75 degrees with pain in the right with weak dorsiflexion all toes right foot. The patient is a known diabetic for 4 years. The patient was treated conservatively.

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The patient then came 02-Aigist-2005 with exacerbation of right sciatica and it was decided, that if no improvement during a period of a month, then to consider surgical treatment. The patient then came to the clinic 10-September-2005, claiming that she is not improving, but clinically she was neurologically free for what conservative treatment was planned.

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The patient then came 04-June-2006 complaining of right sciatica for the last 5 days with SLRS 45 degrees in the right with pain with weak dorsi and planterflexion right foot. New MRI done 05-June 2006 showing wide-based extrusion of L4-5 with secondary segmental stenosis at this level.  She was advised to undergo surgical treatment, but the patient disappeared.

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The patient then came 25-November-2008 complaining of exacerbation of LBP with bilateral sciatica, more the right the last 45 days. MRI lumbar spine performed 15-Novemeber-2008 showing progression of the segmental stenosis at L4-5 with the same wide-based extrusion at the level.

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On examination: the patient  has scoliotic stance and inability to walk more than 150-200 meters and SLRS right side 60 degrees with pain. She had weak dorsi and planterflexion both feet 4/5.

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Decompressive laminectomy of L4 and partial of L5 was performed. Bilateral foraminotomy of bL5 roots was achieved. There was no epidural fat at these levels. Bilateral cleaning of the extruded disc L4-5 and cleaning of the disc space, which was shallow.

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Smooth recovery with considerable improvement of the power of both feet.


Comments

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The patient had prolonged history of LBP and sciatica and most of the time conservative treatment was recommended. The presence of the segmental stenosis, which was progressing led to escalation of the problem and to surgical treatment.

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The extruded disc was wide-based, for what bilateral cleaning of the disc space was performed.

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The expected recurrence rate in this case is below 7%, since the disc space was shallow and empty.

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