Dr. Sergio Rivero wanted to remove the total arachnoid web which meant a incision of about 8 inches and laminectomies of up to 5 vertebrae's. He did not mention hardware to support the spine after laminectomies.
Note: After my failed operation with Dr. Ali Baaj, Dr. Sergio Riverio denied to see me again for a second opinion. Strange reaction I think. You would think he would want to say I told you so!
Note From Your Admission on 12/15/21
Consults by Sergio Rivero, MD at 12/17/21 1029
Consult Orders
1. Consult to Physician/NP [233873937] ordered by Andrade, Francisco JavieG MD at 12/15/21 1604
Neuro Surgery
DATE OF SERVICE:
12/17/202 1
PATlENT:
Name: Terry
MRN:
DOB: 1954
Age: 67 year old
CHIEF COMPLAINT:
Thoracic Cyst
HISTORY OF PRESENT ILLNESS:
History was obtained from patient. The patient has a history of history of chronic back pain, right shoulder replacement (chronic right shoulder infection which he has had for the last 10 months at the site of prosthetic hardware) He has a long history of chronic thoracic and lumbar pain, was seen extensively both in Wisconsin and Mayo Clinic in Rochester, and has undergone multiple epidural injections and steroids for pain control in the past. He has ankylosing spondylosis. Refers intractable lower back pain. He denies any saddle anesthesia. Patient reports intermittent urinary dripped with decreased steam. He denies any bowel dysfunction.
Diagnostic Results:
Labs and Imaging results reviewed.
MRI of T spine with cystic CSF collection behind the chord.
ASSESSMENT:
Thoracic Cyst
Dorsalgia
PLAN:
Recommend CT myelogram of the Thoracic spine.
Obtain Prior MRI5 of the T spine
Will follow for surgical recs,
Medical follow up: will follow while hospitalized
Note From Your Admission on 12/15/21
Progress Notes by Sergio Rivero, MD at 12/17/21 2110
67 yo male with Thoracic Arachnoid web.
Blood pressure 117/72, pulse 73, temperature 36.5°C (97.7 °F), temperature source Oral, resp. rate 18, height 1.727
m (5’ 8”), weight 80.4 kg, Sp02 92 %.
GCS 15
MAEs
A:
CT Myelogram:
IMPRESSION
1. Focal ventral cord displacement and dorsal cord deformity at T5-6, consistent with an arachnoid web or arachnoid
cyst. There has been no significant change since 12/11/2021, given differences in imaging modality.
2. Mild mid thoracic dextroscoliosis, without disc protrusion or cord compression.
Patient provided MRI of T spine 2018
There is evidence of the arachnoid web at the T5 level.
Plan:
Discussed with patient surgery options at this hospitalization of have this scheduled as an outpatient.