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15-NOVEMBER-2011 ZAHER ALI AL-QADUMEE 44 YEARS
HUGE EXTRUDED LEFT FAR LATERAL DISC L4-5 WITH FORAMINAL OCCLUSION.
Anamnesis
The
patient came to the emergency Shmaisani hospital
10-November-2011 complaining of LBP for 3 years
with exacerbation of LBP the last 4 days and
agonizing left sciatica the last 3 days. The
patient came in wheelchair and was unable to
stand to evaluate Romberg or scoliotic stance.
MRI lumbar spine of bad quality done showing
extruded disc L4-5 and bulging L5-S1.
On
examination: SLRS was 70 degrees with pain in
the right and 40 degrees with more pain in the
left. There is weak
dorsi and planterflexion left foot 3/5. There is
hypalgesia of the left lower limb at D12 level.
The deep reflexes are exaggerated in the right
side and there is clonus of the right foot.
The
patient was sent for another MRI of the whole
spine, which was done 11-November-2011
confirming the presence of PCD C3-4, 5-6 and
C6-7 with malacia of the spinal cord at C5-6
level. These changes look old and the patient is
not complaining of. There is fresh PDD
D7-8 right side and it was of soft consistency,
slightly compressing the spinal cord.
Left L5 root foraminotomy was performed and the
left L4-5 lateral mass medial wall was drilled,
so that greater exposure to the far-lateral
space was achieved without violating the
stability of the facet joint. The huge extrusion
was pushing the left L5 root medially to the
right. It was removed in several huge pieces.
Left sided cleaning of the L4-5 disc space. The
epidural fat was missing in the left side and
around the root. After removal of the extrusion,
the neural structures became lax.
Routine
closure of the wound. Smooth postoperative
recovery with improvement of the power of
the left foot.
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Comments
The patient had many problems, among them the
most serious is the PLD L4-5, which is causing
the agonizing pain. The PDD is soft one and it
was decided to leave it for shrinking with time.
The old changes in the cervical spine must be
considered during positioning of the patient
during surgery, so as to avoid positional injury
to the spinal cord during surgery.
The expected postoperative recurrence is still
high around 7%, because the disc space still not
shallow.
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 .
