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The patient came to the clinic 05-November-2006 complaining
of
LBP for 25 years. The last 6 months got exacerbation with left
sciatica. MRI performed 17-June-2006 showed bulging disc L2-3 and
L5-S1. On examination: the patient is limping with exaggerated
scoliotic stance, walking with difficulty. SLRS was 45 degrees in
the right and 30 degrees in the left with weak dorsiflexion all toes
left foot. The patient was advised to perform another MRI, which was
done 06-November-2006, showing PLD L2-3 with upward migration. The
patient when he came the second visit with the MR investigation,
claimed that he improve, for what he was advised for conservative
treatment.
The patient then came 08-December-2006, claiming that his
condition dramatically deteriorate, with urgency and frequency the
last 2 weeks. The patient then was sent for the third MRI of the
lumbar spine, which confirmed the presence of severe stenosis with
disc extrusion at L2-3.
Laminectomy of L2 and partial of L3 was performed and the
compression was so severe, that there were tears in the right side
of the dura with the roots coming out from them. These tears were
not iatrogenic, because meticulous attention was paid for that,
before the discovery of the 3 minitears. There was no covering
epidural fat tissue in the whole area. The bulging through the tears
roots, left untouched. Bilateral cleaning of the L2-3 disc space was
performed and the sequestration was removed and all the compressing
elements were cleaned, after what it was possible to push the roots
back through their tears. Using 6 zero nylon, the tears were
water-tightly repaired and check for leakage with turning the head
up with Valsalva maneuver was negative.
Smooth postoperative recover and the power in both feet
normalized.
Comments:
1. Lumbar canal stenosis with presence of extrusion, both
together, enforce for surgery, as in this case. Conservative
treatment failed and surgery was the only solution for his problem.
2. When there is severe stenosis with severe compression, the
dura can be torn before surgery and these tears becoming evident
during the surgery. Attempt to push the roots inside the compressed
dura only provoke mechanical trauma to them. It is logical to leave
them and decompress the area, after what, they some times return
back simultaneously.
3. The presence of tears with bulging roots without CSF leak,
indicate that there is severe compression, which must be resolved
before attempting to push back the roots.
4. The disc material outside and inside the disc space was
inflammatory in appearance and part of the ligamentum flavum and
posterior longitudinal ligament were swollen, indicating, that some
inflammatory process having place. In the future, some certain
investigations must be done to have more clear picture about such a
case. |
