Successful L4-L5 Laminectomy, Discectomy & Foraminotomy for Lumbar Disc Prolapse

Chief Complaints

A 57-year-old female 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 left lower limb radiculopathy for the past six months. She had a history of similar episodes of back pain, which were previously managed conservatively. The pain was present even at rest, aggravated by physical activity, and did not improve with medications. There was no associated history of motor weakness, bowel disturbances, or bladder dysfunction.

The patient had no significant past medical history of diabetes mellitus, hypertension, cardiac illness, renal disease, thyroid disorders, tuberculosis, or any major previous surgical interventions. There was no history of bowel or bladder dysfunction or other significant comorbid illnesses.

On examination, the patient was moderately built and nourished, conscious, coherent, alert and hemodynamically stable. Neurological examination revealed a positive straight leg raising test on the left side, suggestive of nerve root irritation. Motor power was preserved in both lower limbs, and plantar reflexes were bilaterally flexor. Cardiovascular examination revealed normal heart sounds, while respiratory system examination showed bilateral air entry with no added sounds. There were no focal neurological deficits, bowel or bladder involvement, or signs of systemic illness noted during evaluation.

Upon admission to PACE hospitals, the patient underwent a comprehensive clinical evaluation, along with the patient’s medical history and diagnostic investigations conducted by the Neurosurgery team.

Laboratory and special investigations were conducted as part of the preoperative assessment. Complete blood counts (CBC) revealed microcytic hypochromic anemia with leukocytosis, while renal function tests, liver function tests, serum electrolytes, coagulation profile, and blood sugar levels were within normal limits. Viral screening for HIV, Hepatitis B, and Hepatitis C was negative. Urine analysis was normal. Chest X-ray demonstrated normal heart size with clear bilateral lung fields. Two-dimensional echocardiography showed normal cardiac chambers with good left ventricular and right ventricular function and Grade I left ventricular diastolic dysfunction, without any significant structural abnormalities.

Neuroimaging investigations, including X-ray and Magnetic Resonance Imaging (MRI) of the lumbar spine, demonstrated multilevel degenerative changes. MRI findings revealed Grade I retrolisthesis of L4 over L5 with diffuse disc bulge, peripheral annular tear, ligamentum flavum hypertrophy, and moderate to severe spinal canal stenosis at the L4–L5 level, along with bilateral neural foraminal narrowing and severe lateral recess stenosis causing impingement of bilateral traversing nerve roots. Associated spondylotic and facetal arthropathy changes were also noted at multiple lumbar levels.

Based on the confirmed diagnosis, the patient was advised to undergo L4-L5 Intervertebral Disc Prolapse Treatment in Hyderabad, India, with canal stenosis and left lower limb radiculopathy under the expert care of the Neurosurgery Department. 

After a detailed consultation with Dr. U. L. Sandeep Varma, Consultant Neurosurgeon, a comprehensive neurological assessment and radiological evaluation were performed to determine the most appropriate management and therapeutic approach. The patient presented with low back ache associated with left lower limb radiculopathy since 6 months, which was progressive in nature and not relieved with conservative medical management. MRI of the lumbosacral spine revealed L4–L5 intervertebral disc prolapse with diffuse disc bulge, ligamentum flavum hypertrophy, and moderate to severe spinal canal stenosis with severe bilateral lateral recess stenosis and bilateral nerve root impingement, along with moderate bilateral neural foraminal compromise, consistent with L4–L5 disc pathology causing left lower limb radiculopathy.

The clinical and radiological evaluation revealed features of significant lumbar canal stenosis with nerve root compression at the L4–L5 level correlating with the patient’s symptoms. It was determined that L4–L5 minimal invasive laminectomy and discectomy with foraminotomy under general anaesthesia was the most appropriate surgical intervention. This procedure was aimed at adequate decompression of neural elements, relief of radicular pain, improvement in functional status, and prevention of further neurological deterioration.

The patient and her family members were counselled in detail regarding the diagnosis, surgical procedure, postoperative care, physiotherapy, medication adherence, activity modification, and the need for regular follow-up to ensure optimal recovery and long-term functional outcome.

Following the decision, the patient was scheduled to undergo an L4-L5 Minimal Invasive Laminectomy and, Discectomy Surgery in Hyderabad at PACE Hospitals along with Foraminotomy under the expert supervision of the Neurosurgery Department.

The procedure involved the following steps:

• Patient Positioning and Anaesthesia: The patient is placed in a prone position on the operating table after administration of general anaesthesia. Proper padding and positioning are ensured to avoid pressure injury. The surgical field is prepared and draped under strict aseptic precautions.

• Level Identification and Exposure: The L4–L5 level is identified using fluoroscopic guidance. A small midline or paramedian incision is made, and the paraspinal muscles are gently separated to expose the interlaminar space with minimal tissue disruption.

• Laminectomy and Decompression: A partial removal of the lamina at L4 is performed to access the spinal canal. The ligamentum flavum is excised to decompress the underlying neural elements and improve visibility of the dura and nerve root.

• Discectomy and Nerve Root Decompression: The affected L4–L5 disc is identified and prolapsed disc material is removed carefully in a piecemeal manner. Adequate decompression of the traversing nerve root is achieved, ensuring free and pulsatile neural structures.

• Foraminotomy and Closure: The neural foramen is widened to relieve any residual nerve compression. Hemostasis is secured, and the wound is closed in layers after confirming adequate decompression and stability of neural structures.
  

Postoperatively, the patient was monitored in the Intensive Care Unit (ICU) for hemodynamic stability, neurological status, and immediate surgical recovery. After stabilization, she was shifted to the ward for continued observation and care. Early mobilization was initiated under supervision, and she tolerated ambulation well with improving symptoms and stable neurological findings. The surgical wound was regularly assessed and remained clean, dry, and intact without evidence of infection or discharge. She was continued on medications for pain control, neuropathic symptom relief, infection prophylaxis, gastric protection, and bowel regulation, along with initiation of physiotherapy during the hospital stay.

Upon discharge, the patient was prescribed medications for postoperative nerve healing and nutritional recovery support. Local application was advised for wound care to promote healing and prevent infection. Medications were given for relief of pain and reduction of muscle spasm. Gastric protection was advised to prevent acidity and gastric discomfort during recovery. Treatment was provided for neuropathic pain and associated nerve-related symptoms. Antibiotic coverage was prescribed for prevention of postoperative infection, and bowel regulation support was advised to prevent constipation during the recovery period.

The patient was advised to avoid prolonged sitting for more than 1 hour to reduce strain on the spine. She was instructed to strictly adhere to the prescribed medications as directed. Strenuous physical activities and heavy exertion were to be avoided during the recovery period. The patient was permitted to walk and climb stairs as tolerated. She was also advised that bathing is allowed while maintaining proper wound care precautions.

The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, increasing back pain, weakness in the lower limbs, discharge from the surgical wound, severe or worsening pain, or any new neurological symptoms.

The patient was advised to return for a follow-up with the Neurosurgeon in Hyderabad at PACE Hospitals after 1 month for follow-up assessment and clinical evaluation.

This case highlights L4–L5 intervertebral disc prolapse with canal stenosis and associated radiculopathy presenting with chronic low back pain and failure of conservative management. Surgical management with L4–L5 minimally invasive laminectomy, discectomy, and foraminotomy under general anaesthesia was performed. Postoperatively, there was significant symptomatic improvement with stable neurological status and good recovery at discharge.