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-MARCH-2013 FIKRY ABDEL-RAHEEM YOUSEF 57 YEARS
POSTOPERATIVE HUGE RECURRENCE OF L3-4 WITH DISCITIS.
The patient came to the Shmaisani hospital
24-March-2013 transferred from Palestine,
claiming that he underwent discectomy for for
right far-lateral extrusion L3-4. After the
surgery he immediately deteriorated with more
agonizing sciatica and numbness left leg and
drop left foot and oozing from the wound
resembling CSF leak. The patient underwent three
surgeries for PLD L5-S1 in 1990 and 2 surgeries
last 2 were done by me
The patient underwent CABG 2009 and he stopped
anticoagulants 2 weeks ago.
MRI lumbar spine done 24-March-2013 showing
huge extruded disc L3-4 with up and downward
migration, causing complete occlusion of the
canal. ESR was 65 mm/h and CRP 76 mg/L. Dynamic
X-rays showing slight lateral shift of L3 upon
L4 with mild spondylolisthesis L4-5.
On examination: The patient is unable to stand
to evaluate limping or the scoliotic stance. SLRS was
degrees in the right with pain and 75 degrees in the left
with more pain.
There is complete drop left foot and severe weak
planterflexion 4/5 same foot with weak
dorsiflexion right foot 3/5 and planterflexion
4/5. There is hypalgesia
right L5, S1 and left S1 and analgesia left L5 roots.
The infected wound reopened.
Laminectomy of L3 was done. Inspection for CSF
leak from all the corners of the wound were
sought, but failed. Only several bloody
collections with puss components were found and
remnants of surgicele was seen among the scars.
Exploration of the right side revealed infected
fragments of the upward extrusion, which were
removed. Right sided cleaning of the L3-4 disc
space. The downward migrating pieces were also
removed. Left sided cleaning of the L3-4
disc was done and further removal of the upward
and downward migrating infected disc material
was removed. Meticulous bilateral cleaning of
L3-4 disc space was achieved. The patient was
put with head up the horizontal with Valsalva
maneuver to detect possible CSF leak. It was
negative. Debridement of the infected wound and
water-tight closure of the wound was performed.
Routine closure of the wound.
Smooth postoperative recovery. The power of the
right foot became normal and the power of
planterflexion left foot became normal and
slight improvement of the left drop foot with
recovery of sensation to the analgesic portion
with disappearance of the sciatic pain.
There is still an estimated postoperative
recurrence below 7%, because the disc space is
still not shallow but infected.
There was speculation that CSF leak having place
before surgery, which was ruled out during
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