DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
Severe lumbar spinal stenosis (724.02), lumbosacral spondylosis (721.3), lumbosacral disk degeneration (722.52) and scoliosis (737.39).
POSTOPERATIVE DIAGNOSES:
Severe lumbar spinal stenosis (724.02), lumbosacral spondylosis (721.3), lumbosacral disk degeneration (722.52) and scoliosis (737.39).
OPERATION PERFORMED:
1. Right L4-L5 hemilaminectomy, partial facetectomy and foraminotomy with decompression of the neural elements.
2. Right L5-S1 hemilaminectomy, partial facetectomy and foraminotomy with decompression of the neural elements.
SURGEON: John Doe, MD
ANESTHESIA:
General endotracheal tube.
ESTIMATED BLOOD LOSS:
150 mL.
URINE OUTPUT:
600 mL.
IV FLUIDS:
2 liters of crystalloid.
INTRAOPERATIVE COMPLICATIONS:
None.
SPECIMENS:
None.
DRAINS:
Foley catheter.
DISPOSITION:
At the end of the procedure, the patient was awakened from anesthesia, extubated and transported to the PACU in stable condition.
INDICATIONS FOR PROCEDURE:
The patient is an (XX)-year-old male who has had 4 years of severe right lower extremity pain, greater than low back pain. His symptoms are consistent with a lumbar spinal stenosis found on MRI of the lumbar spine, that demonstrated a synovial cyst of the right L4-L5 facet into the spinal canal, severe degenerative changes in the disks and disk bulges at L4-L5 and L5-S1. An EMG of the lower extremities was performed, that demonstrated acute right S1 radiculopathy. CT myelogram of the lumbar spine was performed. This demonstrated stenosis at L4-L5 with neural foraminal stenosis, more severe on the right, and neural foraminal stenosis greater on the right at L5-S1. AP lateral flexion and extension x-rays of the lumbar spine were performed. These demonstrated degenerative scoliosis, decreased disk height and spurring at all levels of the lumbar spine, minimal L4-L5 listhesis. We discussed the nonoperative and operative treatment options at length.
We discussed the risks of nonoperative and operative treatment options in detail. We discussed the benefits of nonoperative and operative treatment options extensively. All questions were answered. The patient expressed understanding about risks associated with both surgical and nonsurgical treatment. The patient felt like he had failed nonoperative care with nonsteroidal anti-inflammatory pain medications, physical therapy, chiropractic care, acupuncture and interventional pain management. Based on the CT findings of stenosis at L5-S1 and more so at L4-L5, he is a candidate for minimally invasive decompressive surgery. We reviewed lumbar microsurgery together in detail, including images of normal and abnormal anatomy as well as multiple 3-dimensional models. The patient opted to proceed with the right L4-L5 and right L5-S1 laminotomies.
The risks and possible complications of the planned surgery were discussed at length with the patient. These included but were not limited to paralysis, loss of bowel or bladder control, loss of sensation, changes in sensation, weakness including progression of the current weakness or new onset of weakness, nerve damage, infection, anesthetic risks, spinal fluid leak, blood clot, embolism, heart attack, stroke, death, pneumonia, loss of vision, changes in vision, bleeding, scarring, vascular injury, bowel injury, organ failure, reherniation, disk material fracture, development of instability, arachnoiditis and possible need for re-operation. All questions were answered. No guarantees were given. Full informed consent was obtained.
OPERATIVE FINDINGS:
Severe lateral recess and foraminal stenosis on the right at L4-L5 and significant at L5-S1. The L5 nerve root on the right was reddened and inflamed. At the end of the procedure, all visualized neural elements were freely mobile with no further compression identified.
DESCRIPTION OF OPERATION:
The patient was taken to the operating room, and while supine on the gurney, general anesthesia was initiated per the anesthesia service. All appropriate lines and monitors were placed under sterile conditions, including a Foley catheter. The patient was then repositioned prone on the Wilson frame. All bony prominences were well padded. His abdomen was hanging free. Care was taken during positioning of the upper extremities to ensure no undue pressure or tension was applied to the brachial plexus or the peripheral nerves of either upper extremity. The patient’s defibrillator was well padded.
The patient’s back was then prepped and draped in a standard surgical fashion, landmarks were identified and skin markings were made for a midline posterior longitudinal approach to the lumbar spine, L4 to S1. The skin and subcutaneous tissues were injected with lidocaine-containing epinephrine. The skin was incised with a scalpel. Dissection was carried down deep with Bovie electrocautery. Bovie electrocautery was utilized throughout the procedure to maintain hemostasis, except when within the spinal canal, at which point bipolar electrocautery was utilized. Copious antibiotic irrigation was performed at regular intervals throughout the procedure. The Bovie was used to dissect through the superficial fascia down to the deep fascia just to the right of midline at L4-L5. The fascia was incised and the subperiosteal dissection was performed. A probe was placed. Intraoperative x-ray demonstrated the probe was underneath the lamina of L3, so the dissection was carried distally to expose the lamina of L4, the lamina of L5 and the superior half of the lamina of S1 on the right. The dissection was carried out laterally to the facet capsule with care not to damage the facet capsules of L4-L5 or L5-S1 on the right. The ligamentum flavum was then carefully and gently separated from the under surface of the lamina of L4 on the right and L5 on the right and then the L4 and L5 laminae were thinned with the bur and a laminotomy was performed at L4-L5 on the right and L5-S1 on the right with the Kerrison rongeur. Partial facetectomies were performed as well as foraminotomies. The ligamentum flavum was hypertrophic at both levels, more so at L4-L5. The facets were hypertrophic at both levels, more so at L4-L5. The L5 nerve root was visualized and was reddened and inflamed. After the decompressive hemilaminectomies and partial facetectomies as well as foraminotomies were performed with the Kerrison rongeurs at L4-L5 and L5-S1 on the right, the neural elements were carefully and gently examined and determined to be freely mobile. No further compression was identified. The wound was copiously irrigated with antibiotic irrigation. Hemostasis was confirmed. Depo-Medrol was applied over the exposed nerve roots. Because of the patient’s very thin body habitus, thrombin-soaked Gelfoam was applied in the laminotomy defects in lieu of a fat graft. The fascia was then closed watertight with braided #1 absorbable suture placed in interrupted fashion. The wound was again copiously irrigated. The fascia and subcutaneous tissues were injected with plain Marcaine.
The superficial fascia was closed with running 2-0 braided absorbable suture and the skin was reapproximated with deep subcutaneous 2-0 braided absorbable suture placed in an interrupted fashion, and the superficial skin edges were closed with running 4-0 monofilament absorbable suture placed subcuticularly. The skin edges were cleaned and dried. Mastisol and Steri-Strips were applied. A small sterile dressing was applied. The patient was then repositioned supine and awakened from anesthesia. He was extubated and transported to the PACU in stable condition. He tolerated the procedure well. All counts were correct at the end of the case.
