The patient came
to the clinic 12-October-2006 complaining of LBP for 13 years
with exacerbation the last 5 months with inability to set and walk
the last month. He had an exaggerated scoliotic stance and it was
difficult to examine the patient in supine position.
examination: SLRS was 30 degrees in the right and 60 degrees in the
left. KJ and AJ were absent in the right side with almost drop right
foot and hypalgesia of the right L5 territory. The patient was sent
to perform MRI lumbar spine, which showed a very huge disc L3-4 with
bilateral downward migration more in the right.
After identifying the level under image-intensifier, bilateral
foraminotomy L3-4 and flavotomy were performed. The dura was very
thin, that even with great precautions there were two minor defects
in the dura, that through one of them the roots came out and they
were left at their place, because there is no space to push them
back. The extruded disc was hard in consistency and it was
wise to attack it from the left lateral to the L4 axilla. Piece meal
removal was performed to prevent injury to the root. The disc
space was cleaned meticulously from both sides and the osteophyte in
the left side was removed. After removal of the compressive elements
the CSF started to come out and the patient was repositioned in
Trendelinburg position to minimize leakage. After inspection of the
foramina and assurance that no disc fragments left behind, the
bulged roots were easily repositioned back intradurally and
the dural defect was closed using nylon 6 zero water-tightly.
The another defect was so small that coagulation of the defect was
sufficient to close it. The patient was repositioned with the
head over the place of surgery and Valsalva maneuver was performed
to check for CSF leak. No CSF leak. Routine closure of the wound and
smooth postoperative recovery.
1. In this case, the opposite situation in comparison to the
yesterday performed surgery, it was necessary to perform bilateral
cleaning with osteophytectomy. In this case meticulous cleaning of
the disc space was necessary from both sides to minimize the
2. The patient came in bad clinical and morphological situation with
lengthy delay in performing surgery. All these factors minimize the
recovery rate of the patient. This is the rule, and time will show
if he is an exception.