5.

Chest X-ray (16:12 on April 8, 2024)

 No abnormalities detected.

6. Lumbar Spine X-ray (16:04 on April 8, 2024)

 Loss of normal lumbar lordosis.
 Osteophytes and degeneration of lumbar vertebrae.
 Anterior slippage of L4 vertebral body.
 Narrowing of L4-5 intervertebral disc space.
 Bilateral L4 transverse process fractures.
 No abnormalities surrounding the spinal column.

VII. SUMMARY - EXPLAIN - DIAGNOSIS

1. Summary
A 54-year-old female patient was admitted to the hospital with limited
mobility due to back pain and was diagnosed with lumbar disc herniation,
lumbar spinal stenosis. Clinical examination combined with imaging studies
revealed the following signs and symptoms:

 Preoperative manifestations:

 Lumbar spine injury syndrome

 Lower back pain
 Schober (+)
 X-ray: Normal curvature of the spine
 Nerve root compression syndrome
 Increased pain during coughing
 Pain relief when lying down
 Positive Lasègue test
  Pain radiating from the lumbar spine to the left buttock,
thigh, and lower leg
 X-ray: Anterior slippage of the L4 vertebral body with
narrowing of the L4/5 disc space

 Postoperative manifestations:

 No signs of postoperative infection. The patient had no fever, the

wound was dry, mild pain at the wound site, and no redness or
swelling.
 No foraminal compression syndrome: Dorsalis pedis artery
palpable, no calf muscle pain or numbness in both legs
 Pulse palpable in both feet
 No signs of muscle atrophy
 Positive Lasègue test at 40°
 Negative Schober test
 Mild pain at the surgical site, VAS score 2/10

2. Explain

* Preoperative:

 Based on the clinical symptoms: severe lumbar pain, radiating pain to

the left buttock, thigh, and lower leg, increased pain with movement,
decreased pain at rest, coughing exacerbates pain accompanied by calf
numbness. Clinical examination with positive signs: Lasègue, Schober,
combined with imaging studies of the lumbar spine X-ray showed:

 Loss of normal spinal alignment.

 Spurs, degeneration of the lumbar vertebrae.
 Anterior slippage of the L4 vertebral body.
 Narrowing of the L4/5 disc space
 Fracture of the L4 spinous process bilaterally.
 No soft tissue abnormalities around the spine.
From the above evidence, the patient is diagnosed with lumbar disc herniation
with lumbar spinal stenosis.

* Postoperative:

 The patient's postoperative wound was dry, mildly painful, no exudate,

no redness or swelling, and the patient had no fever. Therefore, the
patient is diagnosed with no postoperative infection.
 Upon examination, the dorsalis pedis pulse was palpable. Normal
movement of the toes indicated no compression of blood vessels and
nerves. Based on these findings, the patient is diagnosed with no
foraminal compression.

3. Definitive diagnosis

 Primary disease: Lumbar spine fusion and fusion of lumbar spine facet
joints - posterior fixation through the fourth interspinous space on the
fourth day.
 Comorbidities: None
 Complications: None

VIII. TREATMENT - PROGNOSIS - PREVENTION:

1. Treatment

- Rest and refreshment

- Take medication and do rehabilitation exercises

- Use anti-inflammatory, pain relievers, and muscle relaxants

- Examine and change wound dressings

2. Prognosis:

- Near: good, no complications after surgery

 - Far: cautious, complications of muscle atrophy and joint stiffness
cannot be ruled out

3. Prevention :

- Avoid heavy work and incorrect posture

-Follow your doctor's treatment and exercise instructions

-Adequate nutrition, vitamin D supplementation