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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07-MAY-2012 FATMEH IBRAHEEM AL-HMOUD 65 YEARS
CONDITION AFTER TWO COMPLICATED SURGERIES OF TRANSPEDICULAR FIXATION OF L4-5.
patient came to the clinic 26-April-2012
complaining of numbness both feet for 4 years
with intermittent claudication and inability to
walk more than 50 meters with bilateral sciatica
more the left. The patient underwent elsewhere,
transpedicular fixation 23-March-2012, which was
complicated "no records available" for what
another surgery of transpedicular screw
refixation done 01-April-2012 by the same
neurosurgeon. The patient has dextrocardia and
left renal cyst. LSS-X-ray done before surgeries
showing spondylolisthesis L4-5 with osteoporosis
and old fracture of D12. MRI done
23-September-2010 showing extruded disc L3-4 and
severe stenosis L4-5.MRI lumbar spine performed
27-February-2012 showing shrinkage of the
extrusion of L3-4 with still persisting severe
lumbar canal stenosis L4-5. MRI lumbar spine
performed 23-April-2012 showing the left upper
screw inside the canal.
examination, the patient is limping using
crutches to walk with
exaggerated scoliotic stance with SLRS 80
degrees with pain in both sides, the right
shooting to the left when raised. There is
weak dorsi 3/5 and planterflexion right foot 4/5.
The left foot is completely drop with weak
planterflexion left foot -4/5. The right AJ is absent.
There is analgesia of the left L5 territory.
patient was sent for new MRI lumbar spine and
CT-scan L2-S1 with dynamic studies.
CT-scan done 21-April-2012 showing the left
upper screw inside the canal.
Skeletonization of L3. 4 5
laminae down to the lateral processes. The
left upper screw is inside the canal. The rod in
the left side removed to perform ISIS Highline
Inomed study using transpedicular set. The upper
screw is responding to less than 2 mA DNS
stimulation. The lower responding to 9-10 mA
which is acceptable. The upper left screw
removed. No CSF leak, but there was an old
hematoma in this area. Laminectomy of L3.L4 and
partial of L5. All the compressive elements were
eliminated. Foraminotomy of left L4, L5 roots.
The left L5 root is damaged by the screw.
Discectomy of L4-5 with insertion of TLIF cage
Novel TL Alphatec Spine with osteoset pellets
(Wright Medical Technology Inc) . The same screw
was used to insert through the left pedicle L4
body. Scientex cross connector 40 mm was
used to aid more stability to the construct. The
bone graft substitute was used to fill over both
rods. Guardix-sol 5 ml was used to decrease the
closure of the wound. Smooth postoperative
recovery. The power of the right foot became
normal and the dyseasthesia of the left foot
decreased, but the drop foot still the same.
CT-scan with ORS Visual
reconstruction showing the upper
left screw inside the canal.
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The patient has lumbar
canal stenosis of a progressive course. Surgical
decompression is mandatory in this case.
Despite the fact that the patient underwent 2
surgeries, but the upper left screw still inside
the canal, which is not acceptable.
The drop left foot is due to direct damage of
the left L5 root by the screw. Postoperative
recover is governed by the nature of the damage.
It seems from three similar cases over the
years, that during removal of the screw, which
is inserted inside the canal even if it
penetrate the dural sac, CSF leak is not
happening. This could be explained by
pseudocapsule formation around the screw
contour, if the surgery is done after 45-60 days
after the last surgery. This fact was in detail
explored in this case and the dural tear was
identified, which logically must be in 2 points,
the posterior insertional and posterior
exertional one. Both were free of CSF leak. More
exploration of the defects was not performed, to
avoid triggering the CSF leak.
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 .