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08-JUNE-2002 MARWAN FAWZI
ABU-SAL 40 YEARS PCD C5-6 WITH LEFT FORAMINAL OCCLUSION.
Comments
Cervical disc not recurring, instead in
some cases fusion of the adjacent vertebra take place as in
this case over the long period of time.
Anamnesis
The patient came to the clinic 30-September-2001
complaining o fainting attacks for three ears
with neck pain for 1 year with pain both
shoulders, more the left and numbness left hand.
The last 3 months got numbness left lower limb.
The patient has allergic conjunctivitis.
On examination: The patient has neck pain and
pain when moving it to all directions with weak
extensors both hands 3/5 and left triceps
muscle. SLRS was 90 degrees with pain in the
left with weak dorsiflexion left foot 4/5 and
hypalgesia left S1 root territory.
The patient was sent for
investigation. MRI cervical spine done
06-January-2002 showing extruded disc C5-6 with
left foraminal occlusion with spinal cord
compression. He was advised to perform MRI
lumbar spine and to undergo surgery for the
cervical disc.
Through anterior approach,
discectomy of C5-6 was used, using the C-arm and
the extruded disc was removed, until the dura
was seen at the entire posterior border of the
disc cavity. Smooth postoperative recovery.
The pain in the left upper limb disappeared and
neurologically he is free.
Follow Up
The patient came to the clinic 18-June-2002 with
clean wound and no sensory nor motor deficit.
The patient then came 24-July-2002 complaining
of muscle spasm, but neurologically he was free.
He was given medications.
The patient then came 29-October-2006 telling
that he has the last 4 months clumsiness both
hands, more the left with hypalgesia thumb left
hand.
The patient then came 31-May-2015 telling that
the lest 4 months has neck pain and right upper
limb pain with frozen right shoulder. The
patient was sent for investigations. MRI
cervical spine showing assimilation of C5-6 and
mild stenosis C6-7. Bulge L4-5 and L5-S1
with synovitis right shoulder and complete tear
of the supraspinatus tendon. He was sent to
orthopedics.
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Notice: Head injuries and very urgent surgeries are also
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