Ahmed Azab , Adel Hanafy , Alaa Essa, Khaled Aref, Hesham ...

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Menoufiya Medical Journal 190 Surgical Aspects in Management Vol. 21 No . 2 July 2008 Ahmed Azab et al., The clinical presentation of disc proloapse at the level of upper lumbar spine & dorsolumbar Junction varies from; Low back pain which is usually dull aching pain , may be sever and causing abdominal pain. Pain exacerbates with coughing or valsalva maneuver as it increases the intra thecal pressure, Radicular pain in the dermatomal sensory distribution at the compressed root can be the only pain or associated with low back pain, Cauda equine compression syndrome due to central mechanical compression of the cauda equina, Neurogenic claudications as limited walking tolerance, back pain, much like patients with lower lumbar canal stenosis, Myelopathic manifestations, myelopathy with long tract signs, gait disturbance, weakness or spasticity, Conus medullaries compression resulting in paraparesis & even paraplegia with bowel & bladder dysfunction (3). Diagnostic investigations is very important for surgical decision such as plain radiography which can indirectly suggest pathology such as decreased disc space. The CT scan is one of the imaging modalities used for diagnosis of herniated lumbar disc in addition to its important role in detection of spinal canal stenosis. MRI gives excellent visualization of root anatomy, disc herniation and fragments including foraminal and far lateral pathologies (4). AIM OF THE WORK: This study aims at the evaluation of the clinical and radiological condition of the upper lumbar disc prolapse & the dorsolumbar junction disc and to evaluate the adequet surgical approach posteriorly either just posterior laminectomy only or transpedicular approach. PATIENTS AND METHODS: This prospective study included thirty patients with herniated discs at the upper lumbar & the dorsolumbar junction operated during the last two years. All patients were subjected to the following: Complete history including the inquirements about the age, sex, the onset, duration and nature of the complaints, the history of previous operations, also any associated diseases in addition to inquirement about available radiological investigations. General examination To assess the conditions of the chest, heart, abdomen and lower limbs, which is important to determine whether the patient is fit for surgery or not. Neurological examination including: Evaluation of patient's gait. Back examination for paravertebral spasm, limitation of movement, the lumbosacral angle and curve, any tenderness in the back and scar of any previous operations. Femoral stretch test is tested in both lower limbs. Straight leg raising test is tested in both lower limbs and its angle is recorded. Reflex changes is examined and recording any absence or diminution. Testing any dermatomal loss. Routine laboratory investigations including: Complete blood count. Liver function tests. Renal function tests. Bleeding and coagulation profile. Random blood sugar. Radiological investigations including: Plain X rays of the dorsolumbar and lumbosacral spine with Anteroposterior and lateral films, Stress films, Oblique films. MRI of the dorsolumbar and lumbosacral spine. CT scan was available with 50% of the patients on admission. The clinical indications for surgery were: Progressive neurological deficits. Pain not responding to conservative measures. The posterior surgical approach done for the patients included: The patient is under general anesthesia in a prone position. Midline back incision and incision of the fascia and then retraction of the muscles. Intraoperative fluoroscopy used when needed for levelling. Decompressive laminectomy alone in patient with calcified discs with stenotic canal. Unilateral facetectomy with or without partial or total pedicle removal.
Menoufiya Medical Journal 191 Surgical Aspects in Management Vol. 21 No . 2 July 2008 Ahmed Azab et al., Discectomy will be done for selected cases. Instrumental fusion was done when needed according to preoperativc radiological assessment and the planned surgical procedures. Postoperative follow up clinically and radiographically; Clinically; as regard the improvement of symptoms and signs and occurrence of complications including neurological deficits and infection. Picture( 1 ) MRI LSS showing D12-L1disc prolapse Picture( 2 ) MRI LSS showing L1-L2 disc prolapse Radiologically; by pain X-ray films of dorsolumbar and lumbosacral spine at one month and 6 months postoperatively to assess the development of segmental instability. Postoperative MRI L.S.S will be done when needed if patient deteriorated postoperatively.
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Ahmed Azab *, Adel Hanafy *, Alaa Essa, Khaled Aref, Hesham ...

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Ahmed Azab , Adel Hanafy , Alaa Essa, Khaled Aref, Hesham ...