Munich, 13.03.2001/wa

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