Dr Thomas Hoogland's Medical Report on Anwar Ibrahim
fairplay.
Alpha Klinik Dr. Thomas Hoogland Drs. Horst Dekkers
Facharzre rur Orthopadie Effnerstr. 38. 81925 Munchen
Munich, 13.03.2001/wa
MEDICAL REPORT
Regarding : Examination of Dato Seri Anwar Ibrahim
I have examined Mr. Anwar in Hospital Kuala Lumpur on
February 10, 2001
HISTORY:
The patient is known to have cervial spondylosis of the neck
for many years since a fall from a horse. In September 1998
he was assaulted and fell on his right hip with subsequent
pain in his right buttock and some back pain. The buttock
pain has disappeared, but some back pain remained. About 12
months ago, the patient developed than progressive radiating
pain into the left leg. This became severe in October 2000.
For this reason, he has been hospitalized since the end of
November. The pain was mainly treated with pain medication
and surgery was recommended. At the present time there is
still significant pain in the left leg, radiating into the
dermatomal areas L5 and S1. He has particularly problems
during sitting and after 5 minutes walking. Sneezing caused
severe pain. The patient has a history of gastritis and now
he takes Vioxx as pain medication and Losec for his stomach
problems. There are no known allergies.
PHYSICAL EXAMINATION:
The cervical spine shows significant limitation of rotation,
flexion and particularly of extension. There are normal
reflexes of the upper extremities with normal sensation and
strength. There are normal contoures of the thoracic spine
and there is no tenderness over the thoracic spinous
processes.
The lumbar spine shows hyperlordosis. Extension of the
lumbar spine causes slight pain in the left leg.
The flexion of the lumbar spine is significantly limited
with a finger to toe distance of 60 cm. Flexion of the
lumbar spine causes significant pain in the left leg.
Extension to the left is also limited and painful. Extension
to the right is normal. The strength of the left triceps
muscle is somewhat weaker than on the right side. The
straight leg raising sign on the left side is positive at 45
degrees and there is a crossed Lasegue sign on the right
side at 60 degrees, causing pain in the left leg. The
reflexes of the lower extremities are very brisk. There is
no Babinsky sign. There is hyperreflexia of the right calf
musculature structure with clonus. The reflexes of the left
achilles tendon is less than on the right side. There is
hypesthesia in the S1 distribution on the left side and to a
smaller extend also in the L5 dermatom. There is significant
weakness of the left toe and foot extensors with a strength
of the left foot extensors of 3/5 and of the toe and halux
extensor of 2/5. The so called femural stretch test is on
both sides negative.
X-RAYS:
Plain X-rays of the pelvis and lumbosacro spine of
24.11.2000 show normal hips and facet joint narrowing L4-5
particularly on the left side. There is no spondylolisthesis
and normal disc height.
MRI:
The MRI of the lumbar spine 24.11.2000 shows a big prolapsed
disc L4-5 medially and somewhat to the left with severe
compression of the neural structures. There is ligamentum
flavum hypertrophy with relative stenosis at the level L4-5.
There is narrowing of the facet joint L4-5 on the left side.
The T2-views demonstrate a clear disc herniation L4-5
medially to the left. A MRI of the lumbar spine of
20.12.2000 is unchanged in comparison to the MRI of
24.11.2000.
A CT-scan 20.12.2000 shows a little narrowing of the facet
joint L4-5 on the left side and a disc herniation L4-5
medially to the left side.
A MRI of the cervical spine 20.12.2000 shows C5-6 cervical
spondylosis with no significant narrowing and some
questionable changes in the spinal cord. There is also a
disc protrusion C5-6 on the left side.
CONCLUSION:
The patient is suffering from a big lumbar disc herniation
associated with a narrow spinal canal with ligamentum flavum
hypertrophy L4-5 and facet joint stenosis. The herniation
has caused neural damage and causes significant compromise
of daily activities. Because of this, operative intervention
is necessary to decompress the nerves, alleviate the pain
and restore normal activities. The patient also has cervical
spondylosis with and old lesion to the spinal cord causing
increased reflexes on the lower extremity on the right side.
Because of this cervical situation, there is an increased
risk of neck damage in case of intubation and general
anesthesia. As long as the patient is not operated upon he
should be carefully observed in the hospital because
worsening may occur, because the dura and nerves are
significantly compressed at the L4-5 level.
TREATMENT CONSIDERATION:
Because of the large central disc herniation and the
associated spinal stenosis, there is an increased surgery
risk through a dorsal approach, more over means dorsal
approach that important stabilizing ligaments will be
sacrificed, which may cause significant instability and the
necessity of spinal fusion. Instability and/or spinal fusion
may cause significant postoperative back pain and the
posterior approach to the herniated disc may cause
significant neural damage.
The best surgical decompression of the nerves will be though
a transforaminal endoscopic discectomy. This procedure is
performed through the foramen and does not cause instability
and risky nerve root retraction is in this procedure not
necessary as in this procedure, the herniated disc is
addressed directly. More over, this procedure can and should
be done in local anesthesia, which means significant more
safety as far as the neck condition is concerned and as far
as potential nerve damage is concerned. Also is the risk of
infection with the endoscopical procedure significantly less
than with an open procedure. The risk of residual
significant back pain is also considerably less. Personally
I have performed this procedure in more than 4000 cases
including many indications similar to the case of Mr. Anwar
and we have scientifically established safety and efficacy
of this procedure.
After I have evaluated Mr. Ibrahim and the scans I have
discussed the case with a panel of experts of the Kuala
Lumpur Hospital including 3 orthopedic surgeons, 3
neurosurgeons, 2 radiologists, 1 neurologist and 1
anesthesiologist. The panel agreed, that the endoscopic
procedure would be the safest option for the patient and
that surgery is the necessary and should not be delayed too
long, because of the neurological compromises of the patient
and the existing risk of worsening of the situation.
Subsequently we have investigated the possibility of
performing this procedure in the HKL. It appeared, that the
operating rooms where spinal procedures are normally
performed were on reconstruction. We therefore inspected a
neurosurgical operation suite, which was well equipped
except for an appropriate operation table and C-arm/x-ray
equipment. The was tested in the trauma department. It
appeared that the operating table was very inadequate for an
interventional procedure of the lumbar spine. Moreover the
x-ray equipment was out dated and showing a low limited view
of the lumbar spine. The image intensifier, that is
necessary for spinal endoscopy is much heavier equipment and
has a different electrical power supply as available in HKL.
The anesthesiologists do not have experience with spinal
procedures under local and intravenous anesthesia. The above
equipped cannot be organized with the time frame (4-6 weeks)
that an operation is necessary. There is no question, that
an endoscopic spine procedure in Mr. Anwar case best can be
performed in the specialized Alpha Clinic with experienced
assistance.
FINAL CONCLUSION:
Dato Seri Anwar Ibrahim should undergo endoscopic spinal
surgery with 4-6 weeks, and the procedure would have the
lowest risks and best prognosis if performed at the Alpha
Clinic in Munich. For the time being, the patient should be
closely observed in the hospital as worsening of the
neurological status might occur.
Sincerely,
(Signed by Dr Hoogland)
Hoogland Thomas, M.D., Ph.D. Orthopaedic Surgeon Diplomate
American Board Of Orthopaedic Surgery...