History :
A 39-year-old man presented to Back Pain Relief Specialist in Pune Dr. Sangram Rajale, with chronic low back pain accompanied by bilateral gluteal pain and bilateral lower limb pain (more pronounced on the left side) persisting for the past two years, worsening notably over the last month. He also reported tingling and numbness in both lower limbs, difficulty rising from a seated position and turning in bed, as well as slipping of his left footwear. Additionally, he described experiencing claudication for approximately 10 minutes and disturbances in his sleep.
The patient had:
Moderate weakness in certain leg muscles (EHL and EDL).
Sensory decrease over the left L5 area.
MRI :
The MRI findings reveal a complex array of lumbar spine issues:
A diffuse annular bulge with a posterocentral broad disc protrusion and caudal migration at L2-L3, a diffuse bulge with a posterocentral focal disc protrusion and minimal cranial migration at L4-L5 causing moderate central spinal cord compromise, and a posterocentral focal protrusion at L3-L4 causing severe caudal compromise.
These findings correlate with the patient’s clinical history of chronic low back pain, bilateral gluteal and lower limb pain, tingling, numbness, difficulty with mobility and motor function, slipping of footwear, claudication, and sleep disturbances, indicating significant nerve compression, spinal cord compromise, and functional impairments stemming from the lumbar spine pathology.
Operation :
On November 18, 2022, a surgical procedure was performed on the patient involving L2-L5 laminectomy, decompression, and instrumented posterolateral fusion (PLF) under general anesthesia. During the surgery, an intraoperative dural tear was observed and successfully repaired. The procedure was conducted by Lower Back Pain Doctor in Pune Dr. Sangram Rajale, and the implant used for the fusion was a Jayon implant.
Condition On Discharge :
Four months post-surgery, he reports a significant reduction of 75 to 80% in pain. He can now walk comfortably for 4 to 5 kilometers without any pain and is able to ascend and descend stairs up to 10 storeys without discomfort. Additionally, he notes complete relief from pain in his lower limbs.