This document provides details about a 34-year-old male patient presenting with low back pain radiating to his right leg for 2 years. On examination, he has decreased sensation in the right L4 and L5 dermatome areas and diminished ankle jerk on the right side. Imaging shows a protruded intervertebral disc at the L4-L5 level on the right side. The provisional diagnosis is lumbago with sciatica due to a protruded intervertebral disc at L4/L5. The patient is planned for further evaluation and treatment.

1. Welcome to Pre Operative Case
Presentation

2. DR. SAHED AL IMRAN
MS Phase A Resident (R8)
Department Of Neurosurgery
Unit IV,DMCH

3. PARTICULARS OF THE PATIENT
Mr. Al Amin
34 years of age
Male, Married ,Muslim
Day labour
Right handed
Non Hypertensive , Non diabetic , Non asthmatic
From Motlob, Chandpur got admitted into DMCH on 15th
this year

4. Presenting complaints
1) Low back pain for 2 years
2) Gradual onset of pain in the calf muscle for 8 months
3) Tingling and numbness in the same region for 8 months

5. History of present illness
According to statement of the patient, he was reasonably well
two years ago. Then he developed low back pain. The pain was
intermittent, mild to moderate in intensity, radiating to back of
the thigh & leg down to the heel on rt side, aggravates during
walking, bending forwards, lifting heavy wt & relieves on taking
rest in lying posture & with pain killer.

6. Contd…..
He also complains of gradual onset of pain in Rt calf muscle for
8 months which aggravates during walking & relieves after
taking rest

7. Contd…..
He again mentioned that there is tingling & numbness in Rt leg
for 8 months

8. Contd….
He has no history of
Bowel & bladder dysfunction
Chronic fever
Cough or hemoptysis
significant weight loss

9. History of past illness
He has no significant past history .

10. Family history
 He has 1 daughter and 1 son, all are in good health
 There is no history of similar type of illness prevailing in the
family.

11. Personal History
 He belongs to a lower middle class family
 Non smoker.
 Neither betel leaf nor betel nut chewer
 Nonalcoholic

12. Allergy History
 Not allergic to known drugs or food

13. General examination
 Appearance : Anxious
 Body built : Normal
 Cooperative
 Decubitus : on choice
 Pulse : 68/min
 BP : 110/60 mmHg
 Temperature: 97.8◦ F
 RR : 15/min.
 Anaemia: Absent
 Jaundice: : Absent
 Cyanosis: Absent
 Clubbing: Absent
 Dehydration: Absent
 Oedema: Absent
 Lymph nodes: not palpable
 Thyroid gland: not enlarged
 Hair distribution: normal

14. Systemic examination
 All systemic examinations revealed normal except nervous
system

15. Neurological examination
Higher Psychic Function: Intact
GCS: 15
Handedness: Right
Speech: Normal
Gait: Antalgic
All cranial nerves are intact

16. Motor examination
Upper limb
Normal bulk , tone, power and reflexes bilaterally
Lower limb
Bulk : Normal- both side .
Tone : Normal bilaterally

17. Muscle Power
Right lower limb Left lower limb
5/5 Hip flexion(L2) 5/5
5/5 Knee extension(L3) 5/5
4/5 Ankle dorsiflexion(L4) 5/5
4/5 Extensor hallucis longus(L5) 5/5
5/5 Flexor hallucis longus(S1) 5/5
5/5 Ankle planter flexion(S1) 5/5

18. Motor examination
Reflex :
Right side : Normal knee jerk but diminished ankle jerk.
Left side: Normal knee and ankle jerk.
Planter response : Flexor bilaterally.
Clonus : (Ankle/Patellar ) Absent.

19. Sensory examination
Decreased sensation in right L4 and L5 dermatome area .
All modalities of sensations are normal in both upper and left
lower limb.

20.  There is no cerebellar sign
 No sign of meningeal irritation

21. Straight Leg Raising Test (SLR):
Right side: 50 degree
left side: 90 degree
Toe walking – Difficult ( Rt>Lt)
Heel walking – Difficult ( Rt>Lt)
FABER test - Negative
Femoral stretch test - Negative.

22. Local examination of spine
 No gibbus
 No scoliosis
 No deformity
 No tenderness
 Peripheral Pulses : palpable and normal

23. Provisional Diagnosis

24. Lumbago with sciatica due to PLID on at L4/5 level

25. INVESTIGATIONS

26. X RAY L/S SPINE A/P & LATERAL VIEW

27. MRI L/S SPINE, SAGITAL T2W IMAGE

28. AXIAL IMAGE

29. Clinicoradiological diagnosis
PLID at L4-L5 level on Rt side

30. PLAN

31. Thank you