Dr. Ali Al-Bayyati and Dr. Munir Elias

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The 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.


On 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.


The 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 postoperative fibrosis.


Routine 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.



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