Spinal Elective OP - First Visit

Spinal Elective OP - First Visit - Spine Surgeon The patient presents with a primary complaint of progressive balance problems over the last six months, characterised by frequent stumbles and a sensation of unsteadiness, particularly when turning. Lumbar claudication is reported in both calves, typically after walking approximately 100 metres, relieving with rest. Magnetic Resonance Imaging (MRI) reveals severe spinal stenosis at L4/L5 and moderate stenosis at L3/L4. There is no prior history of spinal decompression surgery. Mr. Arthur Pendelton is a 68-year-old retired construction worker. His past medical history includes a laparoscopic cholecystectomy in 2010 and well-controlled hypertension. He has no known allergies. Current medications include Amlodipine 5mg once daily for hypertension and Atorvastatin 20mg once daily for hypercholesterolemia. He is not currently taking any blood-thinning medications. His recovery from the cholecystectomy was uncomplicated. Mr. Pendelton demonstrates a clear understanding of the proposed treatment plan, which involves surgical decompression to alleviate the spinal stenosis. He explicitly consents to proceed with the operation, understanding the potential risks and benefits discussed. Physical examination reveals a positive dynamic Romberg's test, indicating significant balance impairment. Static Romberg's is also mildly positive. He reports bilateral buttock pain that radiates down the posterior aspects of his thighs into the calves, consistent with neurogenic claudication. There are no trochanteric or groin elements to the pain. Straight leg raise (SLR) test is positive at 45 degrees on the right and 55 degrees on the left, indicative of nerve root tension signs. Neurological examination of the upper limbs reveals symmetrical reflexes (biceps, triceps, brachioradialis 2+). No clumsiness or Hoffmann's sign is present. Lower limb examination shows no dilated veins. Sensation is decreased to light touch in the L5 and S1 dermatomes bilaterally. Peripheral pulses (femoral, popliteal, dorsalis pedis, posterior tibial) are 2+ and symmetrical. Muscle power testing demonstrates hip flexors (L2/3) 4/5 bilaterally, knee extensors (L3/4) 4/5 bilaterally, ankle dorsiflexors (L4/5) 3/5 bilaterally, and plantar flexors (S1/2) 4/5 bilaterally. Long tract signs are absent, and Babinski reflex is negative bilaterally. Reviewed scans confirm severe central canal stenosis at L4/L5, with effacement of the thecal sac and compression of the exiting nerve roots. There is also moderate stenosis at L3/L4. No evidence of previously decompressed areas. Given the patient's progressive balance issues and the presence of moderate stenosis at L3/L4 in addition to the severe L4/L5 stenosis, a whole spine MR has been urgently requested to rule out any cord compression or tandem stenosis at other spinal levels. The scan has been ordered and is scheduled for next week. Mr. Pendelton will be reviewed within two weeks, following the completion of the whole spine MR. The intended procedure to be consented for, pending the updated scan results and confirmation of L4/5 as the primary symptomatic level, is a right-sided L4/5 decompression.