Mr. W.D. is a 58 year old male who was first seen on April 10, 1996 for complaints of left leg pain, left foot numbness and weakness. He failed to respond to conservative treatment. CT on 4/11/96 scan revealed a soft tissue mass in the left lateral recess at the L4 level of the lumbar spine. MRI on 4/12/96 clearly showed an extruded disc fragment at the L4-5 disc level with cephalad migration to the left. The L5-S1 disc had a mild bulge.
4/18/96: Left L4-5 hemilaminotomy with microdiskectomy and excision of free fragments.
A disc bulge was palpated at L4-5 of mild to moderate degree. Since the MRI had clearly shown a superiorly migrated fragment, laminotomy was performed superiorly and several disc fragments were teased from the ventral surface of the dura. There were no fragments extending along the L5 root. The disc space was entered and only small pieces of disc material could be removed.
Mr. W.D. improved and returned to his home state with mild persistent weakness of dorsiflexion of his left foot and residual numbness. He was reinjured when falling from a Captain’s boat chair followed by a twisting injury when working in the engine compartment of his boat. Repeat MRI scanning with and without contrast agent showed scarring and extruded fragment at L4-5 and an increase in the bulge at L5-S1. His left leg pain had returned.
12/9/96: Left L4-5 hemilaminotomy, medial facetectomy, L5 neurolysis with removal of disk fragments. Left L5-S1 hemilaminotomy and microdiskectomy.
Considerable scar tissue was found as expected at the L5-S1 level with small fragments of disk embedded and extruded within the scar tissue. This required performing a medial facetectomy and foraminotomy to free the L5 root. At the L5-S1 level, which appeared to be transitional, a hard bulging disk was found. There were no other pertinent operative findings.
Post-operative course and inclusion of Remote Viewing:
Following surgery, his leg pain was completely relieved. He complained of back pain during the first post-operative week. This slowly led to fluctuating leg pain, left greater than right. Some days, he would be pain free. He remained afebrile and the incision remained intact and normal in appearance.
He was sent for physical therapy with heat, massage and ultrasound with minimal relief. Caudal epidural steroid blocks did not change his pain. On 1/11/97 he complained of bilateral anterior leg pain and bilateral calf pain. There was no evidence of deep vein thrombosis. Straight leg raising was negative.