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
The patient started to complain of
right sciatica for several months, then the last month bilateral
sciatica with inability to ambulate and walk more than 10 meters.
MRI performed, showing extruded disc L3-4 with upward migration
right side with a mass arising from the left L3-4 facet compressing
the left L4 root. There was also spondylolisthesis L3-4. On
examination the patient had weak dorsiflexion right foot.
Considering these data the patient was advised to undergo surgery
for the extrusion , and in case of instability to perform
transpedicular screw fixation. During skeletonization of the L3 and
4 laminae, it was evident that, there was aseptic arthritis of the
facets with fluid coming from the facet joint. There was no
isthmolysis, nor destruction of the bony alignment. There was
mobility limited to the facet joints with the axis of movement in
the sagittal plane. Using high speed drill, the medial part of the
facets was drilled, so as to preserve the facet integrity. Flavotomy
was performed and the right upward extrusion was removed. There was
a ganglion arising from the left facet, which was removed. Reduction
of the spondylolisthesis was achieved easily by traction applied to
the spinous processii. Considering that the patient has an
inflammatory process, and the preserved bony alignments, it was
decided that, it is unwise to use transpedicular screws, taking into
consideration that inflammation could drive to disaster in case of
escalation. After remodeling of the medial part surfaces by
drilling, it was possible to regain fusion of the facets, using
handset cortical 14 mm length 2.7 mm diameter cortical miniscrews
inserted between the the two bony components of the facet vertical
to the surface of the joint and slightly directed upward to resist
forward loads. After that the bony alignments became quite stable
and stress probes were applied to check stability. Closure.
It is the second time I personally
performing the fusion of the facets using this technique. By using
the drilling, it is quite easy and effective in achieving
stabilization in case of preserved bony alignments.
This case is a demonstration, that
minimally invasive surgery is not the field in disc surgery,
because, there are a lot of pathologic findings, could be escaped
without direct exposure. This kind of blind surgery must be
Inflammatory process could lead to
disaster in case of applying heavy constructs, such as
transpedicular screws. In this case fusion was achieved by these
miniscrews and in case of escalation of the inflammation, minimal
distruction to the bone was done.
Surgeon must all the time be
creative in resolving the problems, since there are no 2 identical
operations at all.