DIAGNOSIS:

Lumbar

canal

stenosis

L4-L5,

grade

degenerative

listhesis L4 over L5 with radiculopathy right foot drop

COMPLAINTS ON ADMISSION:
Low back pain x 8 days
Weakness of right foot x 8 days

HOPI: Patient was apparently alright 8 days ago when she started
complaining of pain in her low back which was insidious in onset,
gradually

progressive,

mild

to

moderate

in

intensity,

dull

in

character, aggravated by movement, partially relieved by rest and

associates with heaviness and weakness of right lower limb. Due to
weakness, she head great difficulty in walking without support and
performing

activities

of

daily

living.

She

has

no

difficulty

in

passing stool/urine. She now came to Indian spinal injuries centre

for further management.
No history of trauma / fever / weight loss
No history of morning stiffness

PAST HISTORY
History of DM (on medication)

ON EXAMINATION
Conscious, alert
Vitals - stable

LOCAL EXAMINATION
Right sciatic emergence tenderness present

Neurological examination at the time of admission

Bulk - comparable bilateral reduced
Tone - increase in bilateral lower limbs
Power -upper limb - 5/5 bilateral, all muscle groups
Lower limb

right

left

L2

4+

L3

4+

L4

L5

S1

4+

KJ

AJ

DTR

Plantars right mute, left down going

Sensory absent in right L4-L5 region
PAS
VAC

INVESTIGATIONS

TREATMENT GIVEN
He was evaluated by a team of spine surgeons and was diagnosed as a
case of Lumbar canal stenosis L4-L5, grade I degenerative listhesis

L4 over L5 with radiculopathy right foot drop. After cardiology,

physician, PAC and informed written consent he was taken up OT on
08/06/2016

wherein

posterior

decompression

L3-L4

central

lateral

screw + TLIF right sided L4-L5 was done under general anesthesia.
Post operative period was uneventful. Drain was removed on second
post

operative

day.

He

was

mobilized

and

dept

physiotherapy

was

started. Urologist opinion was taken and advice followed accordingly.

Now he is being discharged in stable condition with the following
advice -

IMPLANT (ZIMMER)
PEEK cage 12 x 26
4 pedicle screw
2 rods

Neurological examination at the time of discharge

Bulk - comparable bilateral reduced
Tone - increase in bilateral lower limbs
Power -upper limb - 5/5 bilateral, all muscle groups
Lower limb

right

left

L2

4+

L3

4+

L4

L5

S1

4+

KJ

AJ

DTR

Plantars right mute, left down going

Sensory absent in right L4-L5 region
PAS
VAC

ADVICE ON DISCHARGE:
Continue physiotherapy as advised
Tab Pregabid 75mg 1 tab twice daily x 3 weeks
Tab Pantocid 1 tab once daily
Tab Hifenac P 1 tab twice daily

In

case

of

any

minor

problems,

consultation

of

family

Physician

should be taken.

If the family Physician feels the need for referral you may report to
emergency services which are open round the clock.

Alternately you may contact Dr. Jahagir (9873987387), Dr. Ashok Reddy
(9494472927),or

Dr.

H.

S.

Chhabra

(9958903390)

or

on

E-mail:-

drhschhabra@isiconline.org.)

Review with Dr. H. S. Chhabra in OPD after prior appointment (from

42255201) on Tuesday / Thursday / Saturday after 6 weeks or SOS

*.*You can have more information about spinal cord injury

(www.elearnsci.org <http://www.elearnsci.org>).

Ankur
Ashok
Apur