This document presents a case of a 65-year-old diabetic and hypertensive woman experiencing low back pain for two years. Imaging showed lumbar canal stenosis at L4-L5 and L5-S1 levels. The patient was scheduled to undergo an interlaminar decompression surgery at these levels. The document describes the patient positioning, incision site, surgical steps including removal of the ligamentum flavum and checking of the intervertebral foramen, closure technique, and potential complications of the surgery.

1. Pre-Operative
Case Presentation
Presented By-
Dr. Syed Shahreor Razzaque, Resident (Phase-B)
NSU- Red
BSMMU
Date: 06.01.2021

2. Salient Features
With kind permission from the Patient
Mrs. Sabina Yeasmin, 65 years old
diabetic, hypertensive housewife
hailing from Mymensing was admitted
in our unit on 23.12.20 with the
complaints of low back pain for last 2
years which was insidious in onset,
intermittent, mild to moderate in
intensity, gradually increasing,
aggravated after bending forward,
coughing, sneezing, straining during
defecation & relieved after taking rest
& oral analgesics.

3. Salient Features
Pain is non-radiating. She also complained of increasing pain
in lower back & cramping pain in both lower limbs after
standing for about 20 minutes or walking for about 200
meters which was relieved after taking rest in sitting or lying
position She didn’t give any history of trauma to the back,
limb weakness, prolonged fever, cough, hemoptysis, anorexia,
unusual weight loss or any other systemic complaints.

4. Salient Features
On examination, tone normal, muscle power is grade 5 in all
muscle groups bilaterally, ankle jerk diminished bilaterally,
plantar response flexor bilaterally, no sensory abnormalities,
SLR 80° bilaterally, femoral stretch test negative, FABER test
negative, no step off sign, all the spinal movements are
restricted due to pain, all the peripheral pulses are present.

5. Provisional Diagnosis
Features of neurogenic claudication due to lumbar canal
stenosis.

6. Investigations

7. X-ray Lumbo-Sacral Spine
A/P and Lateral view
09.12.2020

9. X-ray Lumbo-Sacral Spine
Lateral view in flexion &
extension
09.12.2020

11. MRI of Lumbo-sacral spine
02.09.2020

12. T2W SAGITTAL

13. T1W SAGITTAL

14. T2W AXIAL
L4-L5 L5-S1

15. T1W AXIAL
L4-L5 L5-S1

16. • Lumbar canal stenosis at L4-L5, L5-S1 due to Flavum & Facet
joint Hypertrophy & PLID at L4-L5 and L5-S1.
Clinico-Radiological Diagnosis

17. • Interlaminar decompression at L4-L5 and L5-S1.
Plan

18. Patient Position
• Positioned on a hall frame
• Hips and elbow flexed and
supported
• Torso flat
• Axillary, elbow, inguinal pads
• Abdomen should be hanging free
• No undue pressure on face/eye.

19. Incision
L4
Posterior midline incision centering L2-L4 disc space
S1

20. Deepening through Scarpa’s Fascia

21. Exposing the Thoracolumbar fascia

22. Disscecting TL fascia from spinous process
& supraspinatous ligament

23. Dissection of Paraspinal muscle

24. Detachment of origin of ligamentum
flavum

25. Removal of Ligamentum flavum along
with shaving of upper and lower lamina.

26. Checking Intervertebral foramen

27. Closure
• Check for overall decompression
• Adequate haemostatis
• Irrigation with antibiotic impregnated saline solution
• Self retaining retractors are taken out

28. Closure
• After ensuring hemostasis, fascial
closure is done with 2-0 Vicryl and a
subcuticular closure is performed
on the skin

29. Complications
• Peroperative complications:
• Unintended durotomy resulting in post-operative
CSF leak
• Injury to the nerve root
• Retroperitoneal injury to great vessels and bowel
• Facet joint fracture
• Hemorrhage
• Positioning may lead to injury to the brachial
plexus, pressure points injury
• Wrong level surgery

30. Complications
• Post-operative complications:
• Wound infection, wound dehiscence
• Post operative discitis
• Failure of pain relief
• Segmental instability
• Recurrence of pain due to failed back surgery
syndrome