The patient came 15-October-2007 to the emergency of Al-Shmaisani hospital with agonizing pain and left sciatica with drop left foot for 10 days.

MRI performed 10 days ago showing a huge downward migrating disc L4-5 left side.

On examination: the patient cannot raise his left leg and drop left foot with weak planterflexion same foot with hypalgesia both L5 and S1 territories.

Using Inomed Highline ISIS the operation was performed under TES-MEP control. Bilateral cleaning of the disc space was performed after bilateral foraminotomy both L5 roots. The under axilla both sides were checked and no convincing remnant was noted. It was proposed that the disc fragment was removed during cleaning. Closure of the wound and check for the power of the left foot showed still drop left foot.

The patient in the recovery room checked for foot power, still the same with same sciatica, he was sent another time to the operating room and further downward exploration of the left L5 root revealed the presence of a big piece 10 mm below the disc level. It was removed in several pieces, after what the root became lax and the canal was free of any remaining fragments.

Routine reclosure of the wound and smooth postoperative recovery with improvement of the power of the left foot.

The patient did not remember, that he was operated twice.
 

The patient has left drop foot and the MRI sometimes mislead the surgeon about the actual location of the problem. It could be that the fragment further migrated downward as in this case. It is the sense of the surgeon to have a clear picture between the condition of the patient and the morphologic data during surgery.

In this case the fragment was overlooked, for what he was immediately brought another time to the operating room and the real cause of his dilemma was resolved.

IOM can predict deterioration, but cannot correct and give advice to the neurosurgeon about his sense of the situation and how to resolve it.