case presentation

1. DR.MUMTAZ ALI
NEUROSURGERY DEPARTMENT
JPMC KARACHI

2. History
 45 year old male ,married , right handed , labourer
,resident of nawabshah with NKCM admitted through
opd with c/0
 Lower backache for 4 months
 No hx of weakness , urinary incontinence ,headache ,
dec vision , seizures , difficulty speech , dec hearing

3.  According to my pt he was alright 4 months back then
he developed lower backache while lifting weight. It is
sudden ,radiate to both legs ,griping in nature ,
moderate to severe ,aggravated by walking relieved by
rest and taking medicines.It has no special time of
occurrence .no relation with coughing and
micturition.it is increased in extension of back and
relieved by stooping farward.it is not subsided on
medicine while continous taking of
 No hx of low grade fever , weight loss ,night sweats
,trauma.

4.  No significant lobar , cranial ,cerebellar , endocrine
and systemic symptom
 No significant past medical surgical hx, personal hx .
Family hx , socioeconomic hx , drug hx , allergic hx.
 Level : Lumbosacral spine
 D/D :
 Disc
 Sponydlolisthesis
 Tumor

5. examination
 A middle age pt , well dressed ,good looking ,well oriented
with time place and person with normal built and height
with following vitals and non vitals
 Pulse : 78 bpm , BP : 120/80 mm hg , RR : 16 breaths/min ,
T: A/F
 Pallorness , clubbing , koilynchia dehydration , cynosis ,
jaundice , lymphadenopathy , edema not present.
 No buldge on scalp palpation and scar mark of Vp shunt
presnet on head
 No thydroid swelling is palpated on deglutition
 MME : 30/30
 Primitive reflexs : absent

6. Lower limb Upper limb
 Inspection : SWIFT : absent
 Bulk : symmetrical
 Tone : normal
 Power :5/5 all myotome
 Reflexes : ankle reflex
diminished on right side
 Sensation : dec light touch
and pinprick on lateral
malleolus
 Inspection : SWIFT : absent
 Bulk : symmetrical
 Tone : normal
 Power : 5/5
 Reflexes : +2
 Sensation : normal in all
dermatome

7.  SLR restricted to below 30 on right side
 Non-tender spine
 Lobar , cranial nerve , cerebellar , systemic signs are
not present
 Level : Lumbosacral spine (L5)
 D/D :
 Disc
 Sponydlolisthesis
 Tumor

8. Investigations
 Specific :
 Xray lumbosacral spine (AP XTSX CC)
 MRI lumbosacral spine
 Routine :
 CBC , SUCE , PT/APTT/INR , Hep B n C , CXR
 Relevant :

10. Management
 Admission
 Counselling
 Optimization
 Preop care
 Surgery : Laminectomy and discectomy
 Postop care
 Followup
 Rehabilitation
 Outcome

11. Laminectomy and discectomy
 Shifting : to ot after consent and counselling
 Position : prone with pressure points padded
 Equipments : Microscope , bipolar , neuromonitoring , c-
arm
 Anesthesia : G/A
 Level identification : c-arm
 Incision : Posterior midline
 Disection : skin , subcutaneous tissue ,paraspinal muscle
 Laminectomy :
 Under microscope : discectomy
 Hemostasis secure
 Wound close in layers

12. Complications
 Common complications :
 Infection
 Motor deficit
 Incidental durotomy
 CSF fistula
 Recurrent disc
 POUR
 Uncommon complications:
 Direct injury to neural strcucture
 Injury to great vessels ,urter ,bladder , sympathetic trunk
 POVL
 Wrong site suregry
 Cauda equina
 Compressive peripheral neuropathy
 OUTCOME : success rate /pain free/back to work = 37-75%

13. THANKYOU