My outpatient medical records: 27-year-old woman, two-space lumbar disc herniation, 6 nails, 4 fusion devices, postoperative fat liquefaction, suspected wound infection, dural tear, cerebrospinal fluid leakage, postoperative lifting of the left foot is not strong.
The patient is a 27-year-old female who visited 2021-10-13
When the patient entered the consultation room, a beautiful woman, walking gait did not see anything unusual, for the director of a department of a hospital, the assistant of the industry's well-known national coffee. She told me that her leader had specifically introduced me to come and see me, and I thought it was a normal condition, and came to me for consultation on diagnosis and treatment plans. After she stated the whole treatment process and the problems encountered in the treatment process, I felt the need to share her story with everyone, so I asked her for advice on whether to allow her diagnosis and treatment process to be shared with everyone and do some medical science things, and she readily agreed. I am grateful for her consent and permission.
In my outpatient medical record series, all the cases and films were obtained, I asked patients and their families for their opinions and asked if they would like me to use these materials for scientific research, teaching and science popularization, and the patients and accompanying family members agreed and approved. Thank them for their contributions to medical research, teaching and science popularization.
On August 24, 2021, the patient underwent lumbar disc herniation surgery at a hospital in Xi'an, using 6 screws and 4 fused devices.
The main symptoms before surgery are low back pain, soreness for nearly 1 year, aggravation after the inactivity, relieved after 3 days, and the pain reappeared in June 2021, worsened, and then relieved. Then, on August 17, 2021, a mri was taken in a hospital in Xi'an to suggest lumbar 3-sacral 1 disc herniation, secondary spinal stenosis. Surgery was then performed on 24 August. He was discharged from the hospital 7 days after surgery.
On 13 September, the wound healed poorly, yellow exudation, and was admitted to the hospital to squeeze drainage. On September 17, the ward scraped the wound with a scraping spoon next to the bed. On September 20, he changed to imported antibiotics, and had a high fever at night, 38.6 degrees, which was relieved after stopping antibiotics. 20 September suggests the formation of fluid accumulation in the soft tissues of the lumbar region. Puncture aspirates nearly 20 ml of liquid on September 21. On September 27, the magnetic resonance examination revealed the presence of fluid effusion. On September 28, the puncture aspirated about 25 ml of effusion, and placed the drainage tube, the drainage flow was about 100 m1, On September 30, the drainage tube was removed. On October 7, the magnetic resonance examination was carried out, and the amount of fluid effusion was reduced.
With august 17 lumbar MRI showing lumbar 3-4, lumbar 4-5 disc herniation. Postoperative x-rays suggest lumbar 4-sacral 1 posterior decompression bone graft fusion after internal fixation, no loosening, no rupture, and no displacement of the fusion.
Physical examination: The left foot is restricted when following, the plantar and squat are unrestricted, and the waist is supported when jumping. Stooping is restricted. Left tibia front muscle strength is 3 strong. Feeling decreased muscle strength on the lateral side of the left calf.
Diagnosis: Lumbar 4-sacral disc herniation posterior decompression graft fusion after internal fixation.
Recommendations: Functional exercises. Douyin pays attention to Professor Zhu Lijun of the Department of Orthopedics of Nanfang Hospital and learns core muscle group training. Follow-up.
The language used in the outpatient medical records about its symptoms and treatment process is the patient's self-report, and I make a record. And I didn't see all the complete medical records and surgical records before the patient's surgery. Some of the content of the communication, I did not record in the medical record.
Like what:
The patient asks: Can I go to work now?
I replied: You can go to work, as long as you don't do strenuous activities.
The patient asked: There is no problem with the preoperative movement of the left foot, and now the left foot is weak in extension, is there a problem with this operation?
I answer: There is no problem with the principle of surgical treatment, but there are surgical complications, if the muscle strength of the left foot is normal before surgery, there may be dura material tears and cerebrospinal fluid leakage during surgery, there may also be injuries to the lumbar 4 or lumbar 5 nerve roots, but it should be able to recover, it is also possible to preoperatively protrude larger, compression, during the removal of the intervertebral discs, pulling the nerve root, it may cause damage to the nerve root. However, because the original surgical record was not seen, it is not clear whether there is dural injury and cerebrospinal fluid leakage, and everything is subject to medical records and surgical records.
Patients ask: If you do, do you choose to be open or minimally invasive?
I replied: Open, but if I do it, I may only do a simple discectomy. Not on the internal fixation, not a matter of principle, just like some people like to eat noodles, some people like to eat rice, different doctors, different habits, I personally for young people's simple disc herniation, more just do simple disc resection.
The patient asks: My wound exudate has not been cultured with bacteria, is it not an infection?
I answer: The use of antibiotics after surgery may affect the results of bacterial culture, not necessarily able to grow bacteria, and there may be a leakage of cerebrospinal fluid plus fat liquefaction, if the patient is fatter. The patient's p.s. "I was relatively fat at the time", I said that it was also possible that the fat incision was liquefied, so the wound was not easy to heal.
Figure 1. 20210822 the orthovertebral and overextension x-rays of the lumbar spine before surgery, I personally feel that the stability of this lumbar spine is acceptable, but there are still changes in the anterior flexion and extension of the lumbar 4-5 intervertebral space.
Figure 2. 20210817 the front of the lumbar spine MRI sagittal t2 phase, suggesting lumbar 4-5, lumbar 5 sacral 1 intervertebral disc herniation, lumbar 4-5 disc should fall off into the spinal canal, lumbar 5 vertebral body posterior edge.
Figure 3. 20210817 the preoperative lumbar spine mri sagittal t2 phase, indicating a lumbar 3-4-5-sacral 1 disc herniation, lumbar 3-4 is very light, no treatment is required, and the lumbar 4-5 herniation is larger.
Figure 4. 20210817 the sagittal surface t1 phase of the lumbar spine before surgery, suggesting a herniated lumbar 3-sacral 1 disc and a larger lumbar 4-5.
Figure 5. 20210817 preoperative MRI cross-sectional scan of the lumbar spine suggests mild herniation of l3-4 discs, left paracentral type.
Figure 6. 20210817 preoperative mri cross-section of the lumbar spine suggests l4-5 disc herniation, larger, right-sided.
Figure 7. 20210817 preoperative MRI cross-sectional scan of the lumbar spine, suggesting a herniated L5-S1 disc and a right-sided central type.
Figure 8. 20210822 preoperative cross-sectional scan of lumbar spine CT, suggesting lumbar 4-5 intervertebral disc herniation, right-sided central type, lumbar spinal canal stenosis, lumbar 5 sacral 1 intervertebral disc herniation, right-sided lateral type.
Figure 9. 20210830 the lumbar medial lateral x-ray taken 6 days after surgery, it can be seen that both lumbar 5 lamina have been removed for decompression, so this operation should be done lumbar 4-sacral 1 posterior path total laminectomy decompression, lumbar 4-sacral 1 intervertebral fusion graft fusion fusion, two fusion devices per space, lumbar 4-sacral 1 posterior lateral bone graft fusion internal fixation. It should be a typical plif procedure.
Figure 10. 20210831 the lumbar lateral x-ray and the right femur lateral x-ray taken 7 days after the operation showed that the postoperative internal fixation position was good, but I don't know why the right femur lateral x-ray was taken at that time, and perhaps there may be more obvious pain in the right thigh after the operation. It should be from August 30 to 31, and the patient's lower limb symptoms should be repeated. Otherwise, lumbar spine surgery should not be done, and the femur x-ray should be taken.
Figure 11. 20210904 11 days after surgery, the lumbar spine mri sagittal surface t2 phase, can see the confusion of signals in the incision, high signal liquid aggregation in the incision.
Figure 12. 20210904 11 days after surgery, the lumbar spine mri sagittal surface t2 phase, can see the confusion of signals in the incision, high signal liquid aggregation in the incision.
Figure 13. 20210904 11 days after surgery, the lumbar spine mri sagittal surface t2 phase, can see the confusion of signals in the incision, high signal liquid aggregation in the incision.
Figure 14. 20210904 11 days after surgery, the lumbar spine mri sagittal surface t1 phase, can see the incision signal confusion, incision fluid aggregation.
Figure 15. 20210904 11 days after surgery, the lumbar spine mri sagittal surface t2 phase, can see the confusion of signals in the incision, high signal liquid aggregation in the incision.
Figure 16. 11 days after 20210904 surgery, the lumbar spine MRI cross-sectional scan showed that the signal in the incision was chaotic and the fluid in the incision was concentrated.
Figure 17. 11 days after 20210904 surgery, the lumbar spine MRI cross-sectional scan showed that the signal in the incision was chaotic and the fluid in the incision was concentrated.
Figure 18. 20210920 27 days after surgery, the sagittal surface of the lumbar spine, suggesting confusion in the signal in the incision and liquid aggregation.
Figure 19. 20210920 27 days after surgery, the cross-section of the lumbar spine MRI suggests confusion and fluid aggregation of signals within the incision.
Figure 20. 44 days after 20211007 surgery, the lumbar spine mri suggests fluid aggregation within the lumbar incision, but the mixed signal in the soft tissue around the incision improves.
Figure 21. 44 days after 20211007 surgery, the lumbar spine mri suggests fluid aggregation within the lumbar incision, but the mixed signal in the soft tissue around the incision improves.
Figure 22. 20211007 44 days after surgery, the lumbar mri suggests fluid aggregation in the lumbar incision, but the mixed signal in the soft tissue around the incision improves, but the t1 phase suggests that there is still an abnormal signal in the soft tissue of the posterior part of the surgical field.
Figure 23. 20211007 44 days after surgery, the lumbar mri suggests fluid aggregation in the lumbar incision, but the mixed signal in the soft tissue around the incision improves, but the t1 phase suggests that there is still an abnormal signal in the soft tissue of the posterior part of the surgical field.
Figure 24. 20211007 44 days after surgery, the lumbar mri suggests fluid aggregation in the lumbar incision, but the mixed signal in the soft tissue around the incision improves, but the t1 phase suggests that there is still an abnormal signal in the soft tissue of the posterior part of the surgical field.
Figure 25. 20211007 44 days after surgery, a mri cross-sectional scan of the lumbar spine suggested fluid aggregation in the lumbar incision, but the mixed signals in the soft tissues around the incision improved, but there were still abnormal signals in the soft tissues in the posterior part of the surgery field.
Figure 26. 20211007 44 days after surgery, a mri cross-sectional scan of the lumbar spine suggested fluid aggregation in the lumbar incision, but the mixed signals in the soft tissues around the incision improved, but there were still abnormal signals in the soft tissues in the posterior part of the surgery field.
Figure 27. 20211007 44 days after surgery, a mri cross-sectional scan of the lumbar spine suggested fluid aggregation in the lumbar incision, but the mixed signals in the soft tissues around the incision improved, but there were still abnormal signals in the soft tissues in the posterior part of the surgery field.
Figure 28. 20211013 my outpatient medical records
In this case, there are layers of MRI showing lumbar 3-4 disc herniation, which is very mild and does not require treatment. There is no problem in treating lumbar 4-5, lumbar 5 sacral 1 disc from the surgical range.
Lumbar disc herniation is one of the most basic diseases in spine surgery and should also be one of the most surgical spinal disorders. Although the operation of lumbar disc herniation seems simple, it often goes wrong, and many spinal surgeons have turned their heads in lumbar disc herniation surgery, including myself, and there have also been cases of foot prolapse after lumbar spinal stenosis, intraoperative dural tears and cerebrospinal fluid leakage. Just as general surgeons tend to plant on appendicitis surgery, the simpler the operation and the case, the more likely it is to go wrong because it is not taken seriously enough.