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07-NOVEMBER-2004 MUHAMED SALAMEH ALI 44 YEARS
EXTRUDED DISC C5-6 RIGHT SIDE.
Anamnesis
The patient came to the clinic 23-October-2004
complaining of neck and right shoulder pain for
4 years with exacerbation last 2 months. The
patient cannot sleep due to pain. The radicular
pain reaching the right median distribution. The
patient is a known hypertensive for 6 years. MRI
cervical spine done 05-September-2004 showing
small extrusion of C5-6 right side.
On examination: There is atrophy of supra and
infraspinatus muscles right shoulder with weak
all muscles right upper limb. There is
hypalgesia of the right die of the face, right
upper limb down to right D4 dermatome.
The patient was sent for thorough investigations
and MRI of the brain showed a small lacunar
lesion in the brain stem with extruded disc C5-6
with right foraminal occlusion.
Through anterior approach the C5-6 level was
identified using the C-arm. Discectomy of C5-6
was achieved until the dura was seen at the disc
cavity and special attention was paid for the
right side and the running root. Routine closure
of the wound.
Smooth postoperative recovery and the patient
was sent to the ward.
Follow Up
The patient came to the clinic 20-November-2004
with moderate improvement: the hypalgesia
shrunken to lateral aspect of the right upper
limb with improvement of the power of the right
upper limb.
The patient then came 02-December-2004 with full
power of the right upper limb and hypalgesia of
median distribution of the hand. There was
discussion about treating the right
suprascapular nerve entrapment, but the patient
was reluctant.
The patient then came 30-January-2005 telling
that he has left upper and lower limbs pain with
weak grip, extension left hand, left
triceps with hypalgesia left ulnar distribution
and left L5 and S1 territories. The patient now
is diabetic and sent for investigations. MRI of
the brain showed the same previous data
and fusion of C506 was noted. The patient was
put in conservative treatment and disappeared.
Comments
The patient has multiple pathologies and the
agonizing pain was due to the extruded disc, for
what discectomy was performed to make him able
to sleep.
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