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19-MAY-2009 AZMY FUAD LUKASHA 53 YEARS RIGHT
FAR-LATERAL DISC PROTRUSION OF L4-5 WITH EXTRA-FORAMINAL UPWARD MIGRATION.
Anamnesis:
The patient came to the
clinic 16-December-2007 complaining of LBP for
10 years with right sciatica for 2 years. The
last five days exacerbation of right sciatica.
On examination: the patient
is limping with exaggerated scoliotic stance
with SLRS 0 degree in
the right and 80 degrees in the left. There is
weak dorsiflexion right foot 4/5.
MRI lumbar spine performed
17-December-2007 showed right far-lateral
extrusion L4-5 with foraminal occlusion.
The patient was advised to
continue conservative treatment in the hope of
shrinkage of the extrusion.
The patient came
01-March-2008 claiming that he got improvement
and clinically he was also doing well.
The patient sent for new MRI
lumbar spine, which was done 02-March-2008 which
showed regression with comparison with previous
MRI.
The patient then came
30-April-2009 complaining of escalation of the
LBP with right sciatica after performing
physical effort. On examination he had weak
dorsiflexion right foot -4/5 with SLRS 60
degrees with pain.
MRI lumbar spine done
30-April-2009 showing further extrusion of L4-5
to the same place over the old shrunken one. The
patient was advised to continue in conservative
treatment but he could not tolerate the pain and
he came 17-May-2009 asking for surgery.
Right hemiflavotomy of L45
was performed and using drilling, the facet was
drilled, so that to reach the far-lateral area
from the right. The big piece was migrating
upward out of the foramen. It was removed in
several pieces and cleaning of the shallow disc
of L4-5 was performed from the right. Check for
remnants at the extrusion site was negative and
attempt to expose the laterally running right L4
root was not attempted to avoid unnecessary scar
formation.
Smooth postoperative recovery
with improvement of the power of the right foot.
Comments
The estimated recurrence rate
in this case is now must be very minimal, because the
disc space very shallow.
The patient has far-lateral
disc at L4-5 mostly out of the foramen. Attempts
for conservative treatment succeed in 80% but in
this case it did not work.
The approach in this case is
not standard and all the attempts were necessary
to reach the extrusion and remove it, without
causing destruction to the bony elements.
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Notice: Not all operative activities
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Notice: Head injuries and very urgent surgeries are also
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