Very Interesting Patient !!!

I came across a very interesting case which i am handling since about a month. Patient ( f/46) presented to me with intense leg pain ( left radicular pain). Her pain was from buttock down upto ankle. She came almost crying with pain.

Examination was uneventful , except Extensor Hallusis Longus/ Extensor Digitorum Longus weakness indicating predominantly L5 root involvement. SLR was restricted. So i thought , surely patient is suffering from acute disc prolapse and ordered urgent MRI. To my surprise MRI could not show any significant neuro-compression.

I put her on conservative management. Started her with anti-inflammatory medicines , rest and gabapentine. Patient did improve but still ws complaining of significant pain.

I took an opinion of my neurologist , he conducted EMG/NCV and concluded to be having L5 root radiculopathy with L5 root weakness. He was of the opinion that one should go for a surgery.

My problem was on MRI, I was not able to find a compressive lession neither intracanal nor foraminal or extraformainal.

So i decided to go for L4 and L5 root blocks. Under image intensifier , i injected local anesthetic. Patient improved in her pain immediately. Its been two days since i have injected her and she is doing extremely fine.

I am hopeful that she shall do good, but if her pain shall recover , mostly I am planning to get a frest MRI and CT scan to detect any compressive pathology.

Will post the Update as and when i have results.

till than Cheers !!!

Pseudocyst of Ligamentum Flavum

Today I operated a very unique case. Patient presented with left sided radicular pain. Pain was intense so much so that patient was tossing in the bed. When MRI was done after due physical examinations, it was found that patient had a fluid filled cyst compressing the left L5 root. At first i thought its a synovial cyst arising from L4-L5 facet.

I posted the patient for Microscopic ( Matrix ) fenestration decompression. When i reached the ligamentum flavum. I found it unusually thickened and hypertrophied. facet capsule were looking relatively in order to the routine degneration.

I performed a laminotomy and could found that ligamentum flavum was getting fused with the L4 lamina. With Neurodrill ( Midas Rex ) , we opened the upper border of the ligamentum flavum. I could not dissect the flavum from dura. there were dense adhesion. I tried to open the flavum from it's lateral attachment. I could feel a cystic lession compressing the root. I punctured it and mucoid fluid drained out. Cyst base was again adhered to the dura. I had to find the cleavage plane from the inferior margin of the dura. Gradually, i could take off the cyst en block from the dura.

I have sent it for histopathological report. But i feel that its Mucoid Degeneration of Ligamentum flavum that has formed the cyst.

That's a relatively rare pathology i feel. Lets see i am waiting for the results and than will plan to upload the snaps.