Successful Minimally Invasive L4–L5 Lumbar Discectomy for Disc Prolapse in a 64 Y.O. Male

Chief Complaints

A 64-year-old male patient with a body mass index (BMI) of 20 presented to the Neurosurgery Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of low back pain for the past two months, along with pain radiating to the left lower limb. The pain was present during physical activity as well as at rest and was associated with changes in his walking pattern.

The patient was recently diagnosed with Parkinson's disease and was on medical management under the care of a neurologist. He also had a past surgical history of haemorrhoid surgery performed several years earlier. 

On general examination, the patient was moderately built and adequately nourished, with normal appetite and sleep patterns. He was afebrile, and his vital signs were stable. Neurological examination showed preserved sensory function; however, the straight leg raising test was positive on the left side, indicating irritation of the lumbar nerve root. Increased muscle tone was also noted in all four limbs, which was considered in view of his underlying neurological condition. The remaining systemic examination did not reveal any significant abnormalities.

Upon admission to PACE Hospitals, the Neurosurgery team evaluated the patient for persistent low back pain radiating to the left lower limb, pain during activity and rest, and difficulty while walking. His recently diagnosed Parkinson’s disease and previous surgical history were also reviewed during the assessment.

Neurological examination showed a positive straight leg raising test on the left side, indicating irritation of the lumbar nerve root. Increased muscle tone was also noted in all four limbs. Further clinical evaluation and imaging confirmed L4–L5 intervertebral disc prolapse, with the prolapsed disc compressing the left-sided nerve root and causing lumbar radiculopathy.

Routine preoperative investigations were performed to assess the patient’s general health and fitness for surgery. Based on the clinical findings, neurological examination, and confirmed nerve-root compression, the patient was diagnosed with L4–L5 intervertebral disc prolapse with left lower-limb radiculopathy.

Based on the confirmed diagnosis, the patient was advised to undergo L4–L5 Intervertebral Disc Prolapse Treatment in Hyderabad, India, under the expert care of the Neurosurgery Department at PACE Hospitals.

After a detailed consultation with Dr. U. L. Sandeep Varma (consultant neurosurgeon) and the Neurology team, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach.

Considering the patient’s history of persistent low back pain radiating to the left lower limb, pain during activity and rest, altered walking pattern, and clinical findings suggestive of lumbar nerve-root irritation, further evaluation confirmed L4–L5 intervertebral disc prolapse with left lower-limb radiculopathy. His recently diagnosed Parkinson’s disease and previous surgical history were also considered during treatment planning.

Based on the clinical assessment and investigations confirming nerve-root compression, it was determined that Minimally Invasive L4–L5 Lumbar Discectomy under general anaesthesia was the most appropriate and effective management strategy. This approach was chosen to remove the prolapsed disc fragments, decompress the affected nerve root, relieve pain and numbness, improve mobility, and minimise damage to the surrounding muscles and tissues.

The patient and his family members were counselled regarding the diagnosis, clinical findings, planned procedure, possible risks, expected benefits, and the importance of postoperative care and follow-up.

Following the decision, the patient was scheduled for Minimally Invasive L4–L5 Lumbar Discectomy in Hyderabad at PACE Hospitals under the expert care of Neurosurgery Department. 

The following steps were carried out during the procedure:

• Patient Preparation and Anaesthesia: The patient was taken up for surgery after completing the required preoperative evaluation and obtaining informed consent. General anaesthesia was administered, and the surgical area was cleaned, prepared, and draped under strict aseptic precautions.

• Minimally Invasive Surgical Access: A small vertical incision was made over the lower back and carefully deepened through the underlying tissues. A hemilaminectomy retractor was positioned at the left L4–L5 level to provide access to the affected area while minimising disruption to the surrounding muscles.

• Laminotomy and Ligament Removal: A left L4 laminotomy was performed by creating a small opening in the lamina. The thickened ligamentum flavum was carefully excised to expose the compressed nerve root and provide adequate access to the prolapsed disc.

• Disc Removal and Nerve-Root Decompression: The bulging disc material pressing against the nerve root was identified and removed in small fragments. A foraminotomy was also performed to widen the nerve-root exit passage and relieve the remaining pressure.

• Hemostasis and Closure: After confirming adequate decompression and free movement of the dura and nerve root, bleeding was controlled. A small amount of fat tissue was placed over the nerve root for protection, and the surgical wound was closed in layers with a sterile dressing.
  

Following the procedure, the patient was monitored in the intensive care unit for a few hours before being shifted to the general ward. During the postoperative period, his vital signs remained stable, no new neurological deficits were observed, and the surgical wound remained healthy. He received medications for prevention of infection, pain relief, nerve-related symptom control, stomach protection, bowel regulation, nutritional support, and management of his underlying Parkinson’s disease. The patient was discharged in a hemodynamically stable condition with appropriate postoperative instructions and follow-up advice.

Upon discharge, the patient was prescribed oral medications for prevention of postoperative infection, relief of pain and inflammation, management of nerve-related symptoms, protection of the stomach, nutritional supplementation, bowel regulation to prevent constipation, and continued management of Parkinson’s disease. He was advised to take the medications as prescribed and continue them until the scheduled follow-up visit.

The patient was advised to keep the surgical wound clean and dry, continue Parkinson’s treatment as prescribed, and gradually resume walking and stair climbing as tolerated. He was instructed to avoid heavy lifting, strenuous exercise, prolonged bending, twisting movements, and sitting on the floor during recovery.

The patient was advised to contact the emergency ward at PACE Hospitals if fever, worsening pain, leg weakness, bladder or bowel problems, or wound discharge developed.

The patient was advised to return for a follow-up visit with the Neurosurgeon in Hyderabad at PACE Hospitals after 15 days. 

This case highlights L4–L5 intervertebral disc prolapse with left lower-limb radiculopathy, successfully managed with minimally invasive lumbar discectomy. The procedure relieved nerve-root compression, reduced pain and numbness, and improved the patient’s mobility without any new neurological deficits.