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23-DECEMBER-2012 MUHAMED HASAN QAZZAZ 63 YEARS
HUGE RECURRENT EXTRUDED DISC L4-5 WITH LEFT DOWNWARD MIGRATION.
Anamnesis
The patient came to the clinic 19-December-2012
complaining of LBP for 10 days with numbness of
the left foot and agonizing sciatica. The
patient was operated for extruded disc L4-5 with
left downward migration 10-May-2011 in Qatar. He
improved after that surgery. MRI lumbar spine
performed 15-December-2012 showing huge
recurrence of L4-5 with left upward migration.
On examination: the patient
using crutches, limping with exaggerated scoliotic stance. SLRS was
75
degrees left side with pain and there is
complete drop left foot and weak
dorsiflexion right foot 3/5. There is analgesia
of the left L5 root and hypalgesia left S1 root
with diminished sensation in the left perianal
region with normal micturition and defecation
functions. The KJ is absent in the left and both
AJ.
Complete laminectomy of L4
and left sided L3-4 hemiflavotomy was done. The
left L4 root was identified and foraminotomy of
the root was done. The extruded far upward
migrating disc was partially removed from above
the axilla of left L4 root. The major part of
the extrusion was removed subaxillary and the
disc space of L4-5 was cleaned from the left. No
attempt was paid to explore the left L5 root,
because there was no downward migrating pieces.
Routine closure of the wound.
The power of the left foot became better.
Graphic presentation showing the extension of the
extrusion in the left side.
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Comments
The patient had an
estimated postoperative recurrence rate in the
first surgery above 15% because the disc space
was high. The height of the disc space is now
relatively shallow, for what simple discectomy
with bilateral cleaning is sufficient because
the estimated postoperative recurrence after
this second surgery is below 5%. This was
discussed with the patient and fusion was
considered, but he preferred to undergo
discectomy without fusion.
This far upward migrating disc was achievable as
be performing surgery for PLD L3-4, because a
huge piece was reaching up there. After removing
the most upper part, it was possible to remove
the major upward migrating huge piece from under
the axilla of left L4 root. This case is a
rarity, because removing the upper part was
achieved from above the axilla of the upper disc
level.
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