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  neurosurgery.tv

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.

Comments:

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 abandoned.

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.