CASE PRESENTATION
A 43-year-old man who presented at our emergency room (ER) with complain of left sided lower back pain radiating to left lower limb for 2 years with increased severity since last 10 days, weakness in his left lower limb since 10 days and with history of urinary incontinence ( overflow) since last 2 days. General physical examination revealed no abnormality. On straight leg raising test both legs was found to be 60 degree on the right leg and 50 degree on the left leg, extensor hallucis longus (EHL) and flexor hallucis longus (FHL) was 3/5 on both sides and sensory examination showed reduced sensation on S1 dermatome on the right. MRI of the lumbo sacral spine revealed diffuse bulging of disc with the left postero central / sub articular extrusion at L5-S1 level, thecal compression and impingement of the left traversing S1 nerve root (Figure 1 A,B and C). Presumptive diagnosis of herniated lumbar disc with radiculopathy and cauda equina syndrome was made at ER on the basis of clinical evaluation of patient.
Patient underwent L5 laminectomy. Disc was removed from both side from shoulder end of nerve root. Foraminotomy was performed bilaterally. Intraoperatively only minimal disc fragments was found over epidural space. The dorsal dura matter was tense and bulging at L5-S1 level (Figure 2). Subsequently, dorsal durotomy was performed upon which revealed hard fungating mass similar to tissue texture of nucleus pulposus over the arachnoid membrane ( Figure 3). The mass was dissociative and revelaed itself upon durotomy. Histology report confirmed it to be disc tisue.
Post operatively, patient’s left lower back pain and left leg radiculopathic pain along with left lower limb weakness improved significantly.