Dr. Fuad Al-Masri Syrian neurosurgeon.

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25-JUNE-2013  HUSSEIN ALI AL-QADI  53 YEARS  HUGE EXTRUDED DISC L4-5 WITH RIGHT DOWNWARD MIGRATION AND CAUDA EQUINA SYNDROME.

 

Anamnesis

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The patient came to the clinic 24-June-2013 complaining of LBP for 4 years. The last 2 weeks got exacerbation of LBP with bilateral sciatica more the right with numbness all toes both feet more the right and dripping of urine and constipation, for what Foley's catheter was inserted 2 weeks.

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MRI lumbar spine done 16-June-2013 showing huge extruded disc L4-5 with downward migration bilateral more to the right. Dorsal MRI was normal.

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On examination: The patient is limping with mild scoliotic stance. SLRS was 80 degrees with minimal pain in the right. Weak dorsiflexion right foot 3/5 and left foot 4/5. Weak planterflexion right foot 1/5. There is hypalgesia both L5 roots and left S1 and analgesia right S1 root territories.

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Bilateral L4-5 flavotomy and foraminotomy both L5 roots. The ligamentum flavum was swollen and severely compressing the neural structures. The extruded disc even it is pushing the axilla of S1 laterally, but it was impossible to attack it from under the axilla, because of absence of true anatomical borders to reach it. It was decided to reach the L4-5 disc space and perform discectomy so as to reach the extruded disc, which was reached and pushed to the intradiscal space and removed in one piece. After that the axilla and dural sac became lax and free. Inspection of the left L5 axilla revealed acceptable alignment. Meticulous right sided intradiscal cleaning of L4-5 disc space.

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Routine closure of the wound. Smooth postoperative recovery. The power of left foot dorsiflexion became normal and slight improvement of the planterflexion and dorsiflexion right foot.

 

The extruded disc in MRI causing cauda equina.

 

Comments

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The patient still has an estimated postoperative recurrence around 7%, because the disc space is still not shallow, even with bilateral cleaning.

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Recovery of urination and defecation needs several weeks after decompression.

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When the extrusion is huge and SLRS is acceptable, then separation of the sequester from the annulus fibrosis is the case. In case of still continuous with the annulus fibrosis more compression of the axilla upon motion will trigger more pain.

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The patient has bed sore at the sacral area, which hold suspicion about the real story of his illness. It must be in more protracted period of time.

 

 

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