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31-AUGUST-2010  AHMAD MIRSHED ALI AL-MANASRAH  49 YEARS  EXTRUDED DISC L4-5 WITH LEFT FAR FORAMINAL OCCLUSION AND STENOSIS L3-4.

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 18-February-2004 complaining of LBP for 3 years with left sciatica. The patient was treated conservatively. Then he came 31-March-2008 with same complaints with SLRS left 85 degrees with no sensory of motor deficit and was treated conservatively.

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The patient then came 22-August-2010 with exacerbation of the left sciatica the last week with agonizing pain and limping with exaggerated scoliotic stance. MRI lumbar spine performed 06-December-2003 showed bulge L3-4 and L3-4. SLRS was 30 degrees in the left with pain and weak dorsiflexion left foot and hypalgesia left L5 and S1 root.

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MRI lumbar spine performed 25-August-2010 showing extruded disc L4-5 with left foraminal occlusion and stenosis of L3-4.

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Laminectomy of L4 and partial of L3 and L5 with foraminotomy both L4 and left L5 roots was done. All the stenotic elements were eliminated and the the extruded disc of L4-5 was removed from the left side and left sided cleaning of L4-5 disc space was performed. Inspection of the L3-4 disc disclosed that it is better not to violate it.

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Routine closure of the wound and smooth postoperative recovery with improvement of the power of the left foot and disappearance of left sciatica.


Follow Up

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The patient progressed CSF leak in the second day after discharge, for what he was rehospitalized and was kept for 72 hours in complete bed rest with Mannitol 25 gm TID. The forth day the patient was ambulating and the fifth day was kept in Lazix  and discharged 08-September-2010.

Comments

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The estimated postoperative recurrence rate in this case is around the average because the disc space is still not shallow.

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The extruded disc and stenosis must be resolved so as to resolve all the patient problems over the years.

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Inspection of the dura during surgery revealed no tears or punctuate defects in the dura. Despite this fact, the patient progressed postoperative CSF leak. Interestingly to mention, that the patients operated before and after this case, had dural defects due to severe compression and they were managed accordingly without CSF leak. This case is a demonstration that even in the absence of apparent tears or dural wall defects, CSF leak still can have place after surgery. Using Valsalva maneuver and elevating the head at the end of the surgery are of no help.

 


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