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05-DECEMBER-2011 KHALAF FARES ATIYEH 53 YEARS
WIDE BASED EXTRUDED DISC L5-S1 MORE TO THE RIGHT AND LEFT SIDED SCIATICA.
Anamnesis
The
patient came to the clinic from Iraq
03-December-2011 complaining of LBP for 11 years
with left sciatica for 2 years with numbness
both feet the last 4 months, more to the left L5
territory. MRI lumbar spine of bad quality done
12-September-2011 showing bulge L4-5 and
extruded disc L5-S1 more to the right.
On
examination, the patient now is not limping with
exaggerated scoliotic stance. SLRS was 90
degrees in both sides. There is weak
dorsiflexion both feet with no sensory deficit.
The patient was complaining of a painful click
when turning his spine.
The
patient was sent for new MRI and CT-scan of
L3-S1 with dynamic LSS X-ray, which were done
04-December-2011 showing huge wide-based
extrusion L5-S1 with right downward migration
and compressing the right S1 root, but touching
the left S1 root. There was no bone anomalies,
nor spondylolisthesis nor instability.
Partial bilateral flavotomy
with preservation of the 90% of the layer over
the dura to preserve the epidural fat. The
extruded disc was removed first from the right
side. The left S1 root was exposed. It was
encapsulated with abnormal venous net, which was
coagulated. Bilateral cleaning of L5-S1 disc
space. Xylocain with diprofos was injected to
the left sacro-iliac joint.
Routine
closure of the wound. Smooth postoperative
recovery with improvement of the power of
the feet.
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Comments
The patient has huge extruded disc and the major
extrusion was in the right side, but he
complained of left sciatica. It happens, that
the severely compressed root is not generating
pain, but the less compressed or mechanically
irritated root is suffering as in our case.
Comparing the two roots of S1, the left one was
rich with thickened abnormal veins. It could be
that, as the case in trigeminal neuralgia, the
venous abnormalities could trigger pain, for
what ablation of this venous abnormality was
mandatory with simultaneous preservation of the
epidural fat. This step was taken, because the
major extrusion was in the right, but the
patient was complaining from the left side. Even
left sacroiliitis was ruled out before surgery,
injection with diprofos was performed to the
left SIJ.
The estimated recurrence rate, still around 7%
because the disc space still not shallow.
Reformatted CT-scan ruling out instability or pelvic bone
pathologies.
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 .
