Mr.Hiranwale

July 23, 2024 By Dr. Sangram Rajale In Lumbar Spine, Spinal Infection

History:

A 50-year-old male presented to Back Pain Specialist in Pune Dr. Sangram Rajale with a two-month history of persistent low back pain, which intensifies upon transitioning from sitting to standing and improves slightly while seated. His pain worsens with any movement, making it difficult for him to stand or walk for extended periods. His neuroclaudication distance is approximately 15 minutes, and he reports sleep disturbances. Additionally, he has a recent history of right knee septic arthritis, treated with an arthrotomy a month prior.

Examination Findings:

On examination, by Spine Infection Specialist in Pune Dr Sangram Raale the patient exhibited significant difficulty walking. Range of Motion (ROM) of the lumbar spine revealed :-

  • Flexion: Painful

  • Extension: Painful

MRI of the Lumbosacral Spine:

  1. There is damage and infection in the lower spine area (specifically between the L5 and S1 vertebrae), with signs of infection spreading to the nearby bones and the disc between them.
  2. There’s a buildup of infected fluid (abscess) around this area, pressing on nearby tissues, including the nerves.
  3. The disc between L5 and S1 is bulging, which is slightly narrowing the spinal canal and pressing on the protective layer around the spinal cord and nearby nerves.

Operative Procedure:

The patient underwent a left-sided L5-S1 microdiscectomy on 10/09/2024 under general anesthesia, performed by Top Spine Specialist in Pune Dr. Sangram Rajale.

Condition at Discharge:

  1. On 23/07/2024, the patient underwent L5-S1 wound debridement with decompression and L4-S1 posterior spinal fixation under general anesthesia.

  2. Operating Surgeon: Spine Surgery Specialist in Pune Dr. Sangram Rajale

     

IMPLANTS (GESCO) :

  1. Patient stable.
  2. Suture line healthy and dry – no pus/discharge
  3. Patient ambulating without support
  4. No episodes of fever with chills.
  5. Sensations intact