Successful L4–L5 Laminectomy and Discectomy for Intervertebral Disc Prolapse

Chief Complaints

A 67-year-old male patient with a body mass index (BMI) of 21 presented to the Neurosurgery Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of persistent low back pain associated with right lower limb radiculopathy for the past 9 months. Initially, the pain was aggravated while walking and bending and was managed with physiotherapy and medical treatment. However, for the past 5 days, the severity of pain had increased, and the patient developed pain even at rest, along with numbness in the right lower limb. There were no associated urinary complaints.

The patient had a significant past medical history of carcinoma of the stomach, for which he underwent gastrectomy followed by chemotherapy. He was also a known case of diabetes mellitus and was on regular medical management for glycemic control.

On examination, the patient was conscious, coherent, and oriented to time, place, and person. He was moderately built and nourished, with stable vital signs. Cardiovascular examination revealed normal heart sounds, while respiratory examination showed bilaterally equal air entry. Abdominal examination was soft and non-tender. Neurological examination demonstrated preserved motor power in both lower limbs, with a positive straight leg raise test on the right side and decreased sensation in the right L5 dermatomal distribution, consistent with right-sided lumbar radiculopathy.

Upon admission to PACE Hospitals, the patient underwent a comprehensive clinical evaluation along with a detailed review of his medical history and diagnostic investigations conducted by the Neurosurgery team.

Clinical assessment revealed a history of chronic low back pain associated with right lower limb radiculopathy, which had progressively worsened despite conservative management. The patient subsequently developed pain at rest and numbness in the right lower limb. Neurological examination demonstrated a positive straight leg raise test on the right side and decreased sensation in the right L5 dermatome, while motor power was preserved in both lower limbs. There were no urinary complaints or features suggestive of bowel or bladder involvement.

Laboratory investigations revealed mild anemia and mild neutrophilic leukocytosis, while coagulation parameters were within normal limits. The patient also had a significant medical history of carcinoma of the stomach, status post gastrectomy and chemotherapy, along with diabetes mellitus on medical management.

Radiological evaluation of the lumbar spine demonstrated an L4–L5 intervertebral disc prolapse causing compression of the corresponding nerve root, correlating with the patient's clinical symptoms of lumbar radiculopathy and sensory deficits.

Based on the confirmed diagnosis, the patient was advised to undergo L4–L5 Intervertebral Disc Prolapse Treatment in Hyderabad, India, with right-sided lumbar radiculopathy under the expert care of the Neurosurgery Department.

After a detailed consultation with Dr. U. L. Sandeep Varma (Consultant Neurosurgeon), a comprehensive evaluation was conducted focusing on the patient’s presentation of chronic low back pain with right lower limb radiculopathy of several months' duration, which had significantly worsened in the days preceding admission despite conservative treatment with physiotherapy and medications. The patient also reported pain at rest and numbness in the right lower limb, adversely affecting daily activities and quality of life.

Clinical examination, laboratory investigations including complete blood picture, coagulation profile, and preoperative systemic assessment were reviewed. Neurological evaluation revealed a positive straight leg raise test on the right side and decreased sensation in the right L5 dermatomal distribution, while motor strength was preserved. The patient was also a known case of carcinoma of the stomach, status post gastrectomy and chemotherapy, along with diabetes mellitus on medical management. No bowel or bladder dysfunction was reported, and no major medical contraindications to surgery were identified.

Considering the persistent symptoms, worsening pain, sensory involvement, failed conservative treatment, and L4–L5 disc pathology causing nerve root compression, it was determined that L4–L5 minimally invasive laminectomy and discectomy under general anaesthesia was the most appropriate surgical intervention. The procedure was aimed at adequate decompression of the affected nerve root, removal of extruded disc material, relief of radicular pain and numbness, improvement in mobility, and prevention of further neurological deterioration.

The patient and family members were counselled in detail regarding the diagnosis, surgical procedure, expected outcomes, potential risks and benefits, postoperative rehabilitation, activity restrictions, wound care, medication adherence, warning signs requiring urgent medical attention, and the importance of regular follow-up to ensure optimal recovery and long-term functional improvement.

Following the decision, the patient was scheduled to undergo L4–L5 Minimally Invasive Laminectomy and Discectomy Surgery in Hyderabad at PACE Hospitals under the expert supervision of the Neurosurgery Department.

The procedure involved the following steps:

• Patient Positioning, Preparation, and Localization: Under general anesthesia, the patient was positioned appropriately, and the surgical site was prepared under strict aseptic precautions. The operative field was painted and draped in a sterile manner. Using intraoperative fluoroscopic guidance, the L4–L5 level was accurately localized and marked to ensure precise surgical access.

• Surgical Exposure and Approach: A vertical midline skin incision was made over the localized lumbar level and deepened through the subcutaneous tissues. The paraspinal musculature was carefully dissected to expose the right L4–L5 interlaminar space. During the exposure, subcutaneous tissue was excised and sent for histopathological examination (HPE).

• Laminectomy and Neural Decompression: A right-sided L4 laminectomy was performed to gain access to the spinal canal. The ligamentum flavum was meticulously excised, exposing the underlying dura mater and the right L5 nerve root. Careful decompression was carried out while preserving the surrounding neural structures.

• Discectomy and Nerve Root Decompression: Following identification of the neural elements, a bulging and extruded L4–L5 intervertebral disc compressing the inflamed right L5 nerve root was visualized. The extruded disc fragments were removed in a piecemeal fashion, and a thorough discectomy was performed to achieve adequate decompression. At the completion of decompression, the nerve root was noted to be lax and freely pulsatile, indicating successful relief of neural compression.

• Hemostasis and Wound Closure: Meticulous hemostasis was achieved throughout the surgical field. After confirming adequate decompression and absence of active bleeding, the wound was irrigated and closed in anatomical layers. A sterile dressing was applied, and the patient was subsequently transferred to the recovery area in stable condition.
  

Postoperatively, the patient was monitored in the recovery area and transferred to the ward after four hours in stable condition. Neurological status, vital signs, and the surgical site were regularly assessed, with adequate pain control and aseptic dressing care. The patient was encouraged to mobilize early and ambulate gradually as tolerated. Histopathology of the L4–L5 subcutaneous lesion showed benign adipose tissue with features suggestive of a lipoma, with no evidence of malignancy. The patient was discharged in stable condition with advice on wound care, medications, activity restrictions, and scheduled follow-up.

Upon discharge, the patient was prescribed medications for the prevention and treatment of infection, control of neuropathic pain, and relief of musculoskeletal pain with associated muscle spasm. Gastric protective therapy was advised to reduce acid-related discomfort and support gastrointestinal tolerance. Supplementation for nerve health, recovery, and immune support was provided to aid overall healing. A topical preparation was also prescribed for local wound care and to promote proper healing at the surgical site.

The patient was advised to take adequate rest for 6 weeks and to avoid travel during this period unless in case of emergency. The patient was allowed to take a bath and encouraged to walk and climb stairs as tolerated. The patient was instructed to avoid strenuous exercises and prolonged sitting for more than 1 hour at a time. The patient was advised to strictly follow the prescribed medications and attend regular follow-up as scheduled.

The patient was instructed to contact the emergency ward at PACE Hospitals upon developments of symptoms such as fever, weakness, discharge from the wound, or severe pain.

The patient was advised to return for follow-up with the Neurosurgeon in Hyderabad at PACE Hospitals after 3 weeks. 

This case highlights successful surgical management of L4–L5 intervertebral disc prolapse using minimally invasive laminectomy and discectomy with good neurological recovery. The patient had significant improvement in pain and lower limb function postoperatively with stable recovery. He was discharged in stable condition with advice on rest, medications, and follow-up care.