History :
A 69-year-old gentleman presented with a history of low back pain accompanied by bilateral lower limb radiculopathy for the past five years, which had worsened over the last month. His symptoms began five years ago with a sudden jerk to his back while traveling. Initially, he took medication for a week and experienced some relief, prompting him to return to his hometown. However, his pain persisted, and he gradually lost the ability to walk.
Before coming to hospital he could walk to the farm despite the pain. But as time progressed, he could only manage to go halfway, later, he was unable to walk at all. He also experienced a complete loss of strength in his legs, accompanied by extreme sensitivity to touch, often screaming when touched. He reported tingling and numbness in both lower limbs but had no history of bowel or bladder disturbances. Additionally, there were no known co-morbidities. The patient had been bedridden for the past 15 days due to his worsening condition.
ON EXAMINATION OF LS SPINE:-
The findings indicate varying degrees of weakness in different muscle groups and sensory changes, particularly in the left lower limb. The distal pulses are felt bilaterally, suggesting adequate blood flow to the extremities. These results would be further interpreted in the context of the patient’s history and other clinical information to arrive at a diagnosis and formulate a treatment plan.
– Right Hip Flexion Power: 2+/5, Abduction Power: 4/5, Adduction Power: 2+/5
– Left Hip Flexion Power: 3/5, Abduction Power: 4/5, Adduction Power: 3+/5
– Right Knee Flexion Power: 2+/5, Extension Power: 2+/5
– Left Knee Flexion Power: 3/5, Extension Power: 2+/5
– Ankle Strength:
– Plantar Flexion (PF): Right 5/5, Left 5/5
– Dorsiflexion (DF): Right 4+/5, Left 5/5
– Extensor Hallucis Longus (EHL): Right 4+/5, Left 5/5
– Extensor Digitorum Longus (EDL): Right 5/5, Left 5/5
– Flexor Hallucis Longus (FHL): Right 5/5, Left 5/5
– Flexor Digitorum Longus (FDL): Right 5/5, Left 5/5
– Distal pulses:
– Posterior Tibial: Felt bilaterally
– Dorsalis Pedis: Felt bilaterally
– Sensory Examination:
– Right side: Intact
– Left side: Decreased sensation over the L5 dermatome
MRI :
MRI Lumbar spine WITH WHOLE SPINE SCREENING(02/07/22):-
In summary, the MRI findings show multiple levels of disc bulges and ligament thickening in the lumbar spine, all of which are compressing nerves and potentially causing the patient’s complaints of low back pain, bilateral lower limb radiculopathy (tingling, numbness, and weakness in legs), and loss of strength and sensitivity. These findings correlate well with the patient’s reported symptoms and help explain the progressive nature of their condition.
Degenerative Changes in Lumbar Spine: The MRI shows age-related wear and tear in the lower back.
L1-L2 Intervertebral Disc: There’s a bulging disc at this level that is pressing on nerves and narrowing the spaces where nerves exit the spine. This can cause pain and weakness in the legs.
L2-L3 Intervertebral Disc: Similar to L1-L2, there’s a bulging disc here causing compression on nerves and narrowing of spinal spaces. This can also contribute to leg pain and weakness.
L3-L4 Intervertebral Disc: Another bulging disc at this level, along with a thickening of the ligament (ligamentum flavum), is causing further compression on nerves and spinal cord. This can lead to more severe leg pain, weakness, and possibly difficulty walking.
L4-L5 Intervertebral Disc: Similar findings as L3-L4 with a bulging disc and ligament thickening causing compression on nerves and spinal cord. This can result in significant leg pain, weakness, and potentially affect the patient’s ability to walk.
Operation :
The surgery involved decompressing the spine and fusing the vertebrae from L2 to S1 using specific implants like polyaxial screws and connecting rods. This procedure aims to stabilize the spine and alleviate the compression on nerves and spinal cord, which should help improve the patient’s symptoms and overall spinal function.
Surgery Type: The patient underwent a procedure called L2-S1 posterior spinal decompression posterolateral fusion. This surgery involves decompressing the spinal cord and nerves from the back and fusing the vertebrae together.
Date of Surgery: The surgery was performed on 05/07/2022 under general anesthesia.
Operating Surgeon: The surgeon who performed the surgery is Dr. Sangram Rajale.
Condition On Discharge :
The patient was taken to the intensive care unit (ICU) for a day after surgery because of excessive blood loss. They received a total of 3 units of blood products during and after the operation to replenish their blood volume.
The following findings indicate a remarkable improvement in motor strength, sensory function, and vascular status following the surgery, leading to a complete recovery of the patient’s neurological deficits and functional abilities.
Power in the right and left hip flexion, abduction, and adduction muscles improved to 4/5.
Knee flexion and extension strength in both legs improved significantly to 5/5.
Ankle strength showed complete recovery with all movements (plantar flexion, dorsiflexion, extensor hallucis longus, extensor digitorum longus, flexor hallucis longus, and flexor digitorum longus) achieving a rating of 4/5 bilaterally.
Sensory examination showed complete recovery indicating resolution of the previously decreased sensation.