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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24-NOVEMBER-2008 RAED AHMAD AL-ZUUBY 32 YEARS
SECOND RECURRENT PLD L4-5 RIGHT SIDE.
The patient came to the
clinic 01-November-2008 complaining of right sciatica
during walking for one week. The patient was
operated by me
03-August-2008 for recurrent PLD L4-5.
On examination: the patient
still having mild scoliotic stance with
SLRS 65 degrees in the right with
hypalgesia right L5 root. The power of the feet
was normal. The patient was sent for
MRI lumbar spine performed
05-November-2008 showed another huge recurrence
The old incision was
refreshed and the right upper corner of the L4
lamina was skeletonized. Without removing or
drilling any bony elements, the disc space was
reached and slight cleaning of the disc space
was performed, trying during that to release the
running L4 root medially. After releasing the
root medially, it was possible to remove the
extruded fragments of the annulus fibrosis in
several pieces. Further cleaning of the L4-5
disc space was performed. The running root
became lax the disc space cavity became empty
under visual control.
Smooth recovery with
disappearance of the right sciatica.
The patient in the previous
surgery had wide defect in the annulus fibrosis.
This fact led to higher expectation for the
second recurrence, since the disc space height
was not shallow at that time. Now the disc space
became shallower, for what after performing the
third operation, the expected recurrence rate in
this case became lower than 7%.
There is a small group of
patients, which show some strange phenomenon,
that the disc material grow after surgery.
Despite the meticulous cleaning of the disc
material inside the disc space, new disc
material grow and these patients are liable for
Theoretically speaking, a
cadaver study must be performed to know the
average weight of the disc of L2-3, 3-4, 4-5 and
L5-S1. Also to have information about the weight
of the annulus fibrosis. We tried several times
to weight the mass of the removed disc material,
but there is no reference to judge the percent
MRI studies must be refined,
so as to achieve more information about the
intradiscal architecture of the disc material
and the degree of fragmentation and presence of
any associated inflammatory or other processes.
This can give some keys to better understand the
problem and take appropriate measures.
Usually the recurrence most
of the time is the layers of the slipped
fragments of annulus fibrosis material as in
The actual recurrence rate is
around 30%, but only 7% need surgery. As a
routine all the patients, how come to the clinic
after one month complaining of recurrence of any
signs, new MRI with contrast is performed even
if they are neurologically free.
As noticed in all surgeries
for discectomy, foraminotomy is performed. This
step provide less pain and usually no
neurological deficit in case of recurrence. This
step also has the advantage to release the root
before performing the removal of the extrusion
and give the surgeon the ability, whether to
remove the disc subaxillary or lateral to the
axilla or both.
At this stage of my
knowledge, only the disc space height and the
dimensions of the annulus fibrosis defect, play
the most determinant factors in the recurrence
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Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .