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16-MAY-2007 MAHA ATTA MUSTAFA RAMADAN 42 YEARS PARAPLEGIA
BELOW L1 DUE TO EXTRUDED DISC L1-2 WITH SEVERE SEGMENTAL STENOSIS AT THIS LEVEL.
IATROGENIC INSTABILITY OF L4-5 AFTER 2 SURGERIES FOR LOWER LUMBAR SPINE.
Anamnesis
The patient came to the clinic 12-May-2007 in
wheelchair complaining of complete paraplegia
below L1 level with loss of micturition and
defecation control. The patient underwent
surgery for PLD L4-5 1996 for left sciatica. The
patient then was operated 20-February-2007 for
the "recurrence".
On examination: the patient had profound weak
both quadriceps muscles 1/5, abduction and
adduction of the knees 0/5 and the dorsi and
planterflexion both feet is 0/5. She has no
sensation for micturition and defecation.
MRI lumbar spine performed 25-April-2007 showing
severe stenosis L1-2 with extruded disc
obliterating the space more from the left, with
spondylolisthesis L4-5 due to absence of the
isthmi of L4-5 both sides.
Decompressive laminectomy of L1 and L2 was
performed, using drilling to prevent surgical
trauma to the spinal cord. The isthmi are very
close to the midline. Considering that,
foraminotomy of left L2 root was performed
without violating the stability of the region.
The extruded disc was removed from the left side
lateral to the axilla. Meticulous cleaning of
the disc space of L1-2 disc space from the left.
Under the image intensifier the remnants of the
L4 and L5 were identified and transpedicular
screw fixation with reduction and distraction
was performed between L4 and L5 bodies. Bone
graft was inserted between the lateral processii
of L4 and L5. Routine closure of the wound.
Smooth postoperative recovery.
The patient showed mild improvement of the
quadriceps and abduction and adduction of the
knees immediately after the operation and start
to feel pain in the right lower limb.
Comments
Removal of the isthmi could cause segmental
instability, as in this case. The patient was not complaining
about this instability, because, she was paraplegic below L1
level. This problem will show up in case of improvement of the
neurological status after surgery. So as to avoid this future
situation, transpedicular screw fixation and reduction was
performed.
Careful neurologic evaluation, must be
performed to avoid mistakes in decision making and planning for
surgery. The patients main problem was at the level of L1-2.
Despite this fact, the patient was sent to perform MRI of the
dorsal spine, so as not perform another mistake.
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