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28-NOVEMBER-2013  NASHMIYEH ABED DAHY  65 YEARS  HUGE EXTRUDED DISC L4-5 MORE TO THE LEFT WITH TOTAL SEGMENTAL STENOSIS.

 

Anamnesis

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The patient came to the clinic 24-November-2013 complaining of LBP for 10 years with left sciatica for 1 year down to left L5 territory. She is a known hypertensive for 8 years. The patient receiving Plavix 75 mg daily and it was stopped the day before coming to the clinic.

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MRI lumbar spine done 07-February-2013 showing extruded disc L4-5 right side with complete canal stenosis.

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On examination is limping, in agonizing pain with exaggerated scoliotic stance. There is pain in the neck when turning the head to the right with weak grip, extension right hand and the right triceps muscle 4/5. SLRS was 10 degrees left side with pain. There is weak dorsiflexion left foot 2/5 and right foot 4/5 and weak planterflexion left foot 3/5. There is analgesia left L5 root and hypalgesia left S1 territories.

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The patient was sent for new investigations, and MRI 24-November-2013 showing huge extruded disc L4-5 left side with total stenosis at this level. There are small extrusions of the cervical spine at C3-4, C4-5 and C5-6 levels.

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Decompressive laminectomy L4 and L5. The dura was very thin and adherent to the ligamentous structures, that after their delicate removal, dural tear was seen at the right lower part of the field. Using 4 zero nylon, the defects were repaired, but it seems that with Valsalva maneuver, a very little amount of CSF is coming from the points of needle insertion. Foraminotomy both L5 roots. The L4-5 extruded disc was seen at the left side making the left L5 root as its capsule. To prevent surgical injury to the root, an intradiscal decompression of L4-5 was achieved from the left. After that the huge extrusion started to be extracted out. After removal of the extrusion and left sided intradiscal cleaning of L4-5 disc space, the left L5 root was severely damaged by the extrusion. It regained lax position and acceptable appearance. A piece of muscle was added to the repaired dural defect. Water-tight closure of the wound.

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Smooth postoperative recovery. The power of the right foot became normal and dramatic improvement of the power of the left foot.

 

 

Comments

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The patient still has an estimated postoperative recurrence around 7%, because the disc height is still not completely shallow.

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Notice: Head injuries and very urgent surgeries are also escaped from the plan .

  

 

 

 

 

 

 

 

 

 

 

 

 

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