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16-FEBRUARY-2002 ZAHRA AL-IZZA 70 YEARS
SEVERE LCS L3-4 AND L4-5.
Anamnesis
The patient came
to the clinic 10-February-2002 complaining of LBP
with bilateral sciatica for more than 3 years
with inability to walk more than 50 meters. The
condition is progressing.
MRI of the lumbar
spine showing severe
stenosis both L3-4 and L4-5.
On examination: The patient
is limping with exaggerated scoliotic stance,
walking bended anterior
with SLRS was 60 degrees with pain both sides and
weak dorsi and planterflexion both feet.
Decompressive
laminectomy L3.4, upper border of the L5 and
lower half of L2 with foraminotomy both L4 and
L5 both sides. Due to severe compression at
L4-5, the ligamentum flavum was penetrating the
dura, for what after its removal the dural tear
was stitched by 6 zero nylon. The lower edge of
the field had also tear which was stitched
accordingly. Inspection for overmobility was
negative and the annulus fibrosis both disci
were in good shape. The patient was put in Reverse
Trendelenburg position with Valsalva maneuver
and hyperventilation. No CSF leak. Routine
closure of the wound.
Smooth postoperative recovery.
The power of both feet improved.
She was sent to the ward.
Follow Up
The patient the
came to the clinic 28-February-2002 with
clean wound with improvement of the power of
both feet and normal walking.
Comments
The surgical
intervention for progressive stenosis, the
sooner the better the outcome.
Due to long standing severe
stenosis with severe compression, expect
presence of dural tears, which must be dealt
accordingly.
In retrospective analysis after
long years, in these cases we put the patient in
Trendelburg position to decrease the intradural
pressure.
Use of Thompson frame decrease
the intra-abdominal pressure and venous
bleeding.
Use of Tranexamic acid 1000 mg
I/V increase the clotting process, which make
the field almost dry.
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