Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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02-JULY-2014 WAFA IZZIDEEN MUHAMED AL-ALI 57 YEARS
GANGLION? OF THE RIGHT L4-5 FACET COMPRESSING THE RIGHT L5 ROOT AFTER SURGERY FOR RIGHT L4-5 EXTRAFORAMINAL
The patient was operated by me
20-May-2014 for right far-lateral disc L4-5
with stenosis. The patient came 05-June-2014
with slight improvement with SLRS 10 degrees in
the right with normalization of the power of the
right foot. She still complaining of right
sciatica with hypalgesia right L5 and S1 roots.
MRI lumbar spine done 07-June-2014 showing no
recurrence of L4-5 with swollen right L5 root.
The patient then was admitted to Shmaisani
hospital 15-June-2014 for fainting attack and
MRI of the brain showed mastoiditis right side.
Cardio consultation revealed regurgitation of
the aortic valve. The patient then came
28-June-2014 telling that the LBP with bilateral
sciatica more the right increased the last week.
On examination; the patient is not limping. SLRS was
without pain in the right. Hypalgesia
right L5 and S1 roots territories.
The patient was sent for new investigations: MRI
lumbar spine with contrast done 28-June-2014 showing severe stenosis at
L4-5 with ganglion? arising from the right L4-5
facet, or huge recurrence causing severe foraminal compression.
The old wound refreshed. During superficial
dissection, clusters of the inserted at first
surgery was seen with reactionary changes around
it in the subfascial layers. These reactions
were seen at all sites of dissection, denoting
that the bone graft never became solid and it
gradually completely escaped from the disc space
to the surrounding tissues. Refreshment of the
right upper corner of L5 lamina to follow the
dura up. A huge material of bone graft was seen
intermingled with the ligamentum flavum. The
right L4-5 facet was exposed and all the
reactionary masses were removed. There is no
proper ganglion in the area. Instead there is
the bone graft and a huge recurrence of the disc
material with up and downward migration. The
huge recurrence was removed in several pieces.
The disc space was empty and further cleaning of
disc space was performed to see if any bone
graft was left there. There is no remnants of
bone graft in the disc space. Wide foraminotomy
of the right L5 root was achieved. Routine
closure of the wound.
Smooth postoperative recovery.
The estimated postoperative recurrence is
still was around 7%, but here 2 ml of bone graft was
inserted to the disc space to prevent future collapse of the
area and promote fusion of L4 and L5. That was what supposed
to be in the first surgery.
During this revision, the bone graft will
not ossify within 30-40 min as it was told to us. It
gradually and completely escaped the intradiscal space ,
causing during that reactionary changes around the root,
which was swollen at certain stage, and reactionary changes
around the facet mimicking ganglion and intradiscally
triggering the recurrence.
Do not ever put Hydr'Os inside the disc
space. It will never ossify, instead it will slip out
causing several reactionary changes with trigger to high