Clinical Key Points
A patient with Diabetes and disabling foot drop and pins and needles below the right knee was informed that the foot drop was irrecoverable because of its long duration.
History & Prior Treatment
Mr McG.as a one time brick layer had a long history of back problems from 1980 onwards. He had a significant exacerbation in 1990 when he collapsed in the kitchen and was unable to move for two days. This was associated with numbness in the right foot. This was treated by chiropractic therapy and he became symptom-free until the episode in December 2006 which led him to be hospitalised. At that time he lost the use of his right foot.
In 2010, he still complained of aching and a burning sensation in the right buttock and right groin. He had a combination of numbness and pins & needles in the right shin, top and sole of right foot. He continued to manifest a significant foot drop.
Distribution of symptoms
90% of his problem was the profound right foot drop with additional pins and needles and stabbing pain at the lumbosacral junction. He had to use stick to walk and as a builder he found that he was unstable walking over building sites. He suffered with Diabetes Mellitus.
Investigations
Weight bearing X-rays revealed that the disc height at L5/S1 was slightly reduced.
MRI scan revealed narrowing of the exit doorway for the right nerve & a right paracentral disc protrusion – all embedded in scar.
He had absolutely no movement in all his right toes.
Endoscopic Minimally Invasive Spinal Surgery: - May 2008
Right L5/S1 Spinal Probing and Discography and Endoscopic Lumbar Decompression and Foraminoplasty revealed a posterior protrusion and collection in the left foramen.
Immediate undercutting with the mills and trephines exposed a flattened, broad and highly irritated nerve compressed by overriding bone, facet joint apex osteophyte, thick capsule and a calcified Superior Foraminal Ligament. The nerve was medially displaced by scar. Epidural access was obtained, the capsule and Superior Foraminal Ligament were cut back and undercutting of the facet joint removed the apical osteophyte (bone spur). The nerve was mobilised from the disc and vertebrae and liberated from the granulations. The Safe Working Zone was partially cleared of young scar (granulations).
Outcome
3 weeks afterwards - sensation fully recovered and power already 60% recovered.