Patient History
A 59-year-old gentleman presented with a 2-year history of right lower limb radicular pain, tingling, and numbness. Over the last year, symptoms progressed to urinary urgency and incontinence, with neurogenic claudication after 5 minutes of standing or 10 minutes of walking.
Pre-op Examination
Gait: High steppage with right foot drop
Motor: Complete loss of ankle dorsiflexion bilaterally (0/5), absent EHL/EDL strength, preserved knee and hip function
Reflexes: Knee, ankle, and plantar reflexes absent bilaterally
Sensation: Absent below L2
Radiology Findings
X-ray: Loss of lumbar lordosis, reduced disc height at L4–L5, anterior osteophytes
Findings correlated perfectly with his deficits, suggesting severe chronic compression
Before Treatment
Surgery
L5–S1 Transforaminal Lumbar Interbody Fusion (TLIF) with posterior instrumentation and cage application was performed under general anesthesia.
After Treatment
Dr. Sangram Rajale performed the following advanced spine treatment procedure:
- L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF): A spinal stabilization surgery involving removal of the damaged disc and decompression of spinal nerves.
- Titanium cage and screws were placed to maintain spinal alignment and promote healing.
- The surgery was done under general anesthesia and was completed smoothly.
- This surgical slip disc treatment approach ensured proper decompression and long-term spinal stability.
Post-op Recovery
- Neurological function improved steadily
- By 1 year: Significant recovery of foot strength, no leg pain, urinary symptoms resolved, independent ambulation
- Patient reports complete return to daily activities
This case demonstrates that even in advanced neurological deficit, timely surgical decompression with stabilization can lead to remarkable functional recovery.