Dr. Ali Al-Bayyati and Dr. Munir Elias

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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The patient came to the clinic 13-January-2013 complaining of LBP with left sciatica after falling down 12 days ago. The patient is a known hypertensive for 27 years and stinting was done 6 years ago. MRI lumbar spine done 13-January-2013 (bad quality) showing fracture L1 and L3 with extruded disc L4-5. The patient was walking bended anteriorly. SLRS was 70 degrees both sides with pain in the left with no neurologic deficit. The patient was treated conservatively.


The patient then came 19-February-2013 claiming that she is deteriorating with LBP and bilateral sciatica more the left. The lumbar corset was annoying her, for what she refused to wear it. There is weak dorsiflexion right foot 4/5. The patient was sent for further investigations.


MRI lumbar spine done 20-February-2013 showing further collapse of L1 and L3, extruded disc L4-5 and severe lumbar canal stenosis L2-3, L3-4 with spondylolisthesis L5-S1. Bone density scan confirmed the presence of severe osteoporosis.


Decompressive laminectomy L2,3,4 and partial of L5. Foraminotomy both L4 and L5 roots. Inspection of L4-5 disc revealed that it is hard in consistency and not causing problems, for what it was lift in place without violation. The fractured L3 body was inspected and the collapse was more from the right side. Insertion of the Tsunami Medical inserter was very difficult mandating that the fracture was very old and sclerotic. The balloon was inflated for 4 ml with minimal reduction over 350 Bar. Considering these data, no attempt was done to insert the balloon from the left side. Insertion of the balloon from the right side of L1 showed acceptable reduction and 5 cc vertebroplasty bone cement was inserted. Another balloon was inserted to the left side of L1 and about 8 cc of liquefied cement was inserted with ease. Inspection by the C-arm showed that the material gone with the intraossal veins reaching the central veins of the 2 above vertebrae. Considering this fact further 5 cc of more resilient cement was inserted to the left side of the L1 body. All stages of surgery were done using C-arm control.


Routine closure of the wound. Smooth postoperative recovery.


The liquefied cement slipped inside the intraossal veins 2 level above and one level below.




The patient has several problems, which needs correction. The main problem was the lumbar canal stenosis which was resolved. The extruded disc of L4-5 was hard in consistency and contained, for what in was not violated, for the advantage of the patient. The recent fracture of L1 was expandable, but the old one of L3 was sclerotic and marble-like in consistency.


In the future it is better to distinguish the old and recent fracture in osteoporosis. The old sclerotic one will not be corrected by kyphoplasty ballooning as in the L3 body.


The cement must not be given when it is still in liquid form, because it will escape through the rich venous structures inside the bone elements. 

Follow Up


The patient progressed severe weakness of the left iliopsoas and left quadriceps muscle with anaesthesia of the left anterior aspect of the thigh. The patient was inspected immediately after regaining of the pictures confirming the intraossal slippage of the cement, inspection of the epidural spaces was done to rule out any compression or presence of the cement inside the canal. It could be inside the running epidural veins, which is impossible to visualize.


The neural injury is mostly a chemical and vascular one involving the left D12, L1 and L2 roots.


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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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