PREOPERATIVE DIAGNOSIS:  Lumbar stenosis and neurogenic claudication from L1 through S1.

POSTOPERATIVE DIAGNOSIS:  Lumbar stenosis and neurogenic claudication from L1 through S1.

OPERATIONS PERFORMED:

1.  T12-L1 through L5-S1 laminectomy and spinal decompression with microdissection technique.
2.  Bilateral L2, L3, L4, L5, S1 foraminotomies with microdissection technique.
3.  Intraoperative fluoroscopy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Barbara Doe, CRNA

DESCRIPTION OF OPERATION AND FINDINGS:  On the day of surgery, the patient was brought to the preoperative holding area where IV access was obtained. Prophylactic intravenous antibiotics were administered. The patient was then brought back to the operative suite. While on the hospital gurney, he underwent an uneventful induction of general anesthetic with placement of endotracheal tube. The endotracheal tube was secured in place. TEDs and SCD hoses were applied. He was then placed in prone position on the top of Wilson frame on the operating room table. All pressure points were inspected and appropriately padded, and he was secured to the table. His back was sterilely prepped with Betadine scrub, followed by 70% alcohol, followed by povidone-iodine paint. The paint was allowed to dry, and once dried, the area was draped in the usual fashion.

Intraoperative fluoroscopy was brought into the field to correlate the cutaneous landmarks on the patient's skin with the underlying spinous processes, and based on this area, we marked from T12-L1 through L5-S1. We infiltrated this area with local anesthetic and then used a #10 scalpel to incise the skin down to the lumbodorsal fascia across this area. Hemostasis was obtained with monopolar and bipolar electrocautery. Once we identified the lumbodorsal fascia, Cobb periosteals and monopolar electrocautery were used to create a subperiosteal dissection, dissecting the soft tissues including the musculature, fascia and the paraspinal fat off the spinous processes, lamina and medial facets from T12 to S1 bilaterally. Adson-Beckman retractor and right-angled cerebellar retractors were used to retract the soft tissue. Once this exposure was obtained, a Penfield 4 was placed into the lowest interlaminar space and x-rays were obtained confirming it to be at L5-S1. Based on this information, we then used the Horsley bone cutter and Leksell rongeur to remove the spinous processes in superficial half of the lamina of L1, L2, L3, L4 and L5 with inferior part of T12 and superior part of S1. The Midas Rex drill and AM8 drill bit were then used to thin the remaining lamina to the thickness of an eggshell. Then, combination of 2, 3, and 4 mm Kerrison rongeurs were used to remove the remaining lamina and underlying ligamentum flavum creating a central trough to decompress the thecal sac exposing the underlying dura.

Once the central decompression from T12-L1 through L5-S1 was completed, we then used the Midas Rex drill to thin out the lateral recesses in attempt to undermine the joints to gain access to the nerve roots as they are going to the neural foramen. We then used 2 and 3 mm Kerrison rongeurs to remove the significantly hypertrophied ligamentum and allow recesses as well as the osteophytes and stenosis out of the lateral recesses compressing the L2 through S1 nerve roots bilaterally. We identified L2 through S1 nerve roots bilaterally using microdissection technique. I tracked out the neural foramen and used a 2 mm Kerrison rongeur to open up the foramen laterally and to remove soft tissue out, as the nerve roots were going up the foramen to decompress them. A complete foraminotomy was performed L2 through S1 bilaterally.

At this point, the thecal sac and nerve roots were well decompressed. A Woodson dissector was used to pass along the nerve roots laterally. We were able to palpate the pedicles. The nerve roots were noted in the neural foramina on either side without any additional compression. The patient did have some mild scoliosis appreciated during the decompression, but there did not appear to be severe instability and the facets were kept intact to minimize the risk of developing instability. Now that the decompression was completed and no significant soft tissue remained, we proceeded to copiously irrigate the wound with antibiotic solution. We inspected the area for any evidence of dural rents and none were seen.

Then, a small Hemovac drain was placed and laid over the thecal sac and drawn out through a separate stab incision. It was secured with a Vicryl suture to the skin. We then proceeded to close and retractors were then removed. The wound was copiously irrigated once more and hemostasis was felt to be adequate. The paraspinal musculature was reapproximated in a couple of places to help decrease the space with 0-Vicryl sutures. The fascia was closed with multiple interrupted 0-Vicryl sutures. Subcutaneous tissues were closed with inverted 2-0 Vicryl sutures and the skin was closed with running 3-0 nylon suture. The blood loss for this was approximately 450 mL. Cell Saver was used and the blood lost at the time of surgery was given back to the patient, 230 mL of blood was given back to the patient via the Cell Saver.

At this point, antibiotic ointment, Telfa gauze and foam tape were placed on the patient's wound. He was placed back on the hospital gurney. He was extubated. He was noted to be moving all extremities. The patient was taken to the recovery room in stable condition.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:  Recurrent lumbar disk herniation L4-5, lumbar spinal stenosis, lumbar sclerosis, and lumbar disk degeneration.

POSTOPERATIVE DIAGNOSES:  Recurrent L5 disk herniation, lumbar stenosis, scoliosis, and disk degeneration.

OPERATIONS PERFORMED: 

1.  Lumbar posterolateral arthrodesis, L2-L5.

2.  Posterior segmental spinal instrumentation with Synthes, L2-5.

3.  Posterior lumbar interbody fusion, L4-5, and application of Synthes PEEK interbody fusion cage spacer, 13 mm x2, at L4-5.

4.  Local bone graft. 

SURGEON:  John Doe, MD 

ASSISTANT:  Jane Doe, MD 

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Bradford Doe, MD 

ESTIMATED BLOOD LOSS:  500 mL.

DESCRIPTION OF OPERATION:  The patient was placed prone on the Jackson table, four-poster frame. Bony prominences were padded. The back was prepped and draped. Using a #10 blade, a longitudinal midline incision, centered over the lumbar spinous processes, was carried through the skin, subcutaneous tissue, dorsolumbar fascia and the scar tissue of previous surgeries at L3-4 on the left and L4-5 on the right. Cerebellar retractors x2 were placed. Intraoperative radiographs were obtained. The spinous processes of L3, L4, L5 were exposed bilaterally. There is a fracture of the transverse process of L4 on the right. Damage to the facets was noted and the facet capsules at L3-4 and L4-5 were removed. The spinous process at L5, L4 were removed as well as the lamina of L5, L4, L3. There was significant epidural fibrosis on the right side at L4-5 and left side at L3-4. A 2 mm dural tear on the left side at L4-5 was noted during the dissection. It was repaired with 5-0 Prolene and we augmented the seal with fibrin glue prior to closing the incision. The L4-5 disk was exposed bilaterally. There was nuclear material extruding from the hole of the annulus on the center of the left side disk at L4-5 and diskectomy was performed with 15 blade, pituitary rongeurs, Scoville curettes, and nerve hook were used to mobilize and remove disk material and curettage of cartilaginous endplates. On the right side, there was an extruded piece of disk lying against the lateral aspect of the L5 nerve which was removed. A 15 blade was used to make a posterior retaining annulotomy. Straight up and down-biting pituitary rongeurs, Scoville curettes, and nerve hook were used to mobilize and remove disk material. Under distraction, afforded by the 13 mm paddle spacer, two 13 mm interbody fusion cage spacers were packed with local bone graft and then packed into the disk space taking care to countersink the cages anterior to the posterior cortices of L4 and 5. A Karlin spinal retractor was placed. After irrigation, the pedicles at L3, L4, L5 were entered with the starting awl and bur. Pedicles were probed and sounded and 7 x 45 mm screws were placed into the pedicles of L3, L4, L5 in satisfactory position. The dorsal surfaces of transverse processes of L3-4 were decorticated with the bur. Final images using the image intensifier showed that the screws and cages were in satisfactory position. The screws were connected with contoured quarter-inch rods and secured with the collar. Tisseel and Gelfoam placed. The fascia approximated with 0 Vicryl, subcutaneous tissue with 2-0 Vicryl over a 7 mm J-P drain, the skin with subcuticular 4-0 Monocryl. Steri-Strips and dressing applied. The patient was then transferred to PACU.

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DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Multilevel lumbar stenosis with facet hypertrophy and segmental instability.

POSTOPERATIVE DIAGNOSES:  Multilevel lumbar stenosis with facet hypertrophy and segmental instability, multilevel facet ligamental hypertrophy and bilateral L4-5 synovial cysts.

OPERATIONS PERFORMED:

1.  L2-3 through L5-S1 laminectomies and spinal decompression with microdissection technique.
2.  Resection of bilateral L4-5 synovial cysts.
3.  Bilateral L3 through S1 foraminotomies with microdissection technique.
4.  L3 through S1 segmental fusion/arthrodesis utilizing bilateral L3, L4, L5 and S1 pedicle screw instrumentation and bilateral L3 through S1 posterolateral fusion with application of INFUSE bone morphogen protein, type 2, plus bone autograft.
5.  Intraoperative somatosensory-evoked potential and electromyelography monitoring.
6.  Intraoperative fluoroscopy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA

ANESTHESIA:  General.

ANESTHESIOLOGIST:  Bradford Doe, CRNA

DESCRIPTION OF OPERATION AND FINDINGS:  On the day of surgery, the patient was brought to the preoperative holding area, where IV access was obtained and prophylactic intravenous antibiotics were administered. The patient was then brought back to the operative suite. While on the hospital gurney, he underwent an uneventful induction of general anesthetic with placement of endotracheal tube. The endotracheal tube was secured in place. Additional IV and arterial access was obtained. SSEP and EMG monitoring leads were placed and baseline studies were obtained. TEDs and SCD hose were applied. A Foley catheter was then inserted and then the patient was placed in prone position on the top of Wilson frame on the operating room table. All pressure points were inspected and appropriately padded, and he was secured to the table. We then sterilely prepped the patient's back with Betadine scrub, followed by 70% alcohol, followed by povidone-iodine paint. The paint was allowed to dry, and once dried, the area was draped in the usual fashion.

Intraoperative fluoroscopy was brought into the field to correlate the cutaneous landmarks on the patient's skin with the underlying spinous processes, and a sterile marker was used to mark from the L2-3 interspinous space down to the L5-S1 interspinal space. We infiltrated the skin in midline from these two points and then used a #10 scalpel to incise the skin down to the lumbodorsal fascia. Hemostasis was obtained with monopolar and bipolar electrocautery. We then did a subperiosteal dissection with Cobb periosteals and monopolar electrocautery, dissecting the spinal processes, lamina and facets from L2-3 to L5-S1 bilaterally.  Right-angled retractors were placed into the wound to maintain visualization of these structures. A Penfield 4 was placed into the wound, to confirm our levels.

Once confirmed, we then proceeded to dissect further laterally, lateral to the facets, exposing the transverse processes of L3, L4, L5 bilaterally, as well as the ala of S1 bilaterally. Once they were skeletonized, clearly delineated and freed of soft tissues, McBride retractors were placed into the wound. Then a Horsley bone cutter was used to remove the spinous processes of L3, L4, L5 and S1. A Leksell rongeur and a combination of 2, 3, 4 and 5 mm Kerrison rongeurs were then used to remove the spinal lamina and the underlying ligamentum flavum. We noted that the patient did have severe stenosis with triangulation of the thecal sac across each of these levels. Once the central decompression was performed, we then proceeded more laterally to remove the ligamental hypertrophy and medial facet, causing severe lateral recess stenosis across these levels.

This was accomplished with the combination of 2, 3, and 4 mm Kerrison rongeurs as well as the Midas Rex drill and the AM8 drill bit. During this dissection, we also identified synovial cyst formation at L4-5 bilaterally, which was removed and was significantly adherent to the thecal sac but was dissected without any form of drill injury or spinal fluid leak. This was impinging upon the thecal sac to a point where it was indented with an impression left even after removal of the synovial cysts. As we dissected out laterally and freed the lateral recesses of significant soft tissues, ligament hypertrophy and underlying facet overgrowth, we did encounter some epidural venous bleeding as the area was decompressed, which was easily controlled with bipolar electrocautery and thrombin-soaked Gelfoam.

We then identified the nerves roots to L3, L4, L5 and S1 bilaterally. This was most severe at L5 bilaterally, where partial facetectomies had to be completed to decompress the nerve roots. The nerve roots above these levels were very hyperemic, but after they were decompressed, we could pass a Woodson dissector out the neural foramen without any additional compression seen. Now that our foraminotomies were completed and decompression from L2-3 through L5-S1, we proceeded with our stabilization procedure. The patient did have abnormal movement across each of these segments and this was most severe at L4-5. DePuy Spine Expedium pedicle screw instrumentation was used for our stabilization. Under fluoroscopic visualization, we then placed the screws from L3 to S1 bilaterally.

We initially began at L3. We identified the right eye of the facet. I palpated the medial pedicle and then passed the pedicle probe down of the pedicle to L3, on the left side, to a depth of 50 mm and under direct fluoroscopic visualization. We then palpated the void created by passing the probe, and no cortical breakthrough was appreciated. We then placed a 6 x 15 mm polyaxial Expedium titanium screw at that level. We repeated this process at L4, L5, and S1, and it was done bilaterally. At L3, 6 x 15 mm screws were used; at L4, 6 x 55 mm screws were used; at L5, 6 x 50 mm screws were used and then at S1, 7 x 50 mm screws were used.

We did palpate each of the pedicle probe voids, prior to placement of screws, to ensure that there was no violation of outer cortex and to make sure there was no vascular or neural involvement. After all 8 screws were in place, we then stimulated each of these screws for EMG thresholds for nerve root irritation and all values were above 16 and deemed to be acceptable. X-rays and fluoroscopy were used throughout this process, as each of the screws were placed and a final x-ray was obtained, confirming their alignment. The screws from L3 to S1 on either side were connected with a 5.5 mm titanium rod that was secured with inner set screws, torqued to a rate of 80 inches per pound. The two rods were then fully secured with a crosslink that was a soft, X10 Crosslink system, that is 45 mm in length.  It too was locked and counter-torqued in the recommended manner by the company.

Satisfied with our solid construct, we then proceeded with our decortication process. We decorticated the transverse processes and lateral facets from L3 to S1 bilaterally. We copiously irrigated the entire wound with antibiotic solution and then proceeded with our bony fusion construct. An INFUSE bone morphogen protein type 2 large kit was used.  A collagen sponge was divided lengthwise, impregnated with the bone morphogenic protein in the manner recommended by the company, and then the bone autograft obtained doing decompression morselized, skeletonized, fragmented and divided in equal parts. It was placed on the collagen sponge, and the sponge was rolled in Taco-type fashion. The two sponges were then placed on either side of the instrumentation laterally, over the transverse processes that had now been decorticated. The additional bone autograft that had been morselized and obtained during our decompression was now placed over this to provide further slurry and construct for bony ingrowth.

At this point, our retractors were removed. A small Hemovac drain was placed and we proceeded to close. The paraspinal musculature was closed with approximately 5 interrupted 0-Vicryl sutures to reapproximate the dead space. Then, the fascia was closed with multiple interrupted 0-Vicryl sutures. The subcutaneous tissue was closed with inverted 2-0 Vicryl sutures, and the skin was closed with running 3-0 nylon suture. The blood loss from surgery was almost 1450 mL; however, Cell Saver was used at the time of surgery and the blood lost during this process was given back to the patient. A total of 3 units were administered.