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  • jayd10033
    Participant
    Post count: 69

    Hell Doctor, I believe I mentioned I was having XLIF and I’m one day post-op and discharged home.

    I was told incisional pain could be alot, and it is much more so than with the previous microdiscectomy I had. It is VERY painful to move or adjust in bed. Pain meds help somewhat, but not a lot. I’m hoping this is normal (I am so fearful of another discitis, and this pain feels somewhat like that did I think b;c of the psoas being involved in the approach).

    My actual question is about my abdomen, which seems bloated, and swollen. My surgeon said it’s due to a combination of gas,fluid from surgery, and not having a BM yet, and it will go down in time. Is that your experience as well?

    How many days will the pain be this limiting barring complications? I can get up and walk around, but I have some discomfort in the front of my thigh, etc.

    Will keep the group posted on progress if it’s helpful.

    Details from surgery below:

    HARDWARE:

    SPACER MOD XLW 10 DEG 8X22X50MM – LOG2222714
    SPACER MOD XLW 10 DEG 8X22X50MM
    NUVASIVE INC
    ML1639
    Anterior 1 Implanted

    DRAINS: NONE.

    CONDITION: STABLE TO PACU.

    FINDINGS: L3-4 SPONDYLOSIS S/P DISCITIS, LEFT L3 NERVE ROOT PERINEURAL SCARRING S/P DISCITIS, RETROLISTHESIS.

    PROCEDURE: The patient was transferred here from the operative holding area to the operating suite where general anesthesia was administered by the Department of Anesthesia. Sequential compression devices were placed on the bilateral calves because for DVT prophylaxis. Perioperative intravenous antibiotics were was administered. Neuromonitoring leads were placed.

    POSITIONING: The patient was positioned in the lateral decubitus position with the left side up on the Amsco bed with care to position the cervical spine in appropriate position and the axilla free of compression. All bony prominences were well padded as well as the ulnar nerves at the elbows and peroneal nerves at the knees.

    PREPPING AND DRAPING: The patient was prepped and draped in the usual sterile fashion and manner utilizing ChloraPrep solution and Ioban draping.

    INCISION AND EXPOSURE: Following surgical time-out and radiographic localization, a 4 cm incision was made in the left flank over the L3-4 disc space in a transverse manner. Electrocautery was utilized to achieve hemostasis. Blunt dissection was utilized to dissect through the subcutaneous fat. With great care in the lumbar fascia was incised with Metzenbaum scissors. The external oblique, internal oblique and transversalis musculature was spread bluntly. The transversalis fascia was snipped and the retroperitoneal space was entered. Digital dissection was utilized to develop the plane lateral to the psoas and to reflect the peritoneal sac anteriorly. Retroperitoneal fat was gently dissected. The psoas muscle was palpated.

    SEQUENTIAL TUBE DILATION: Sequential tube dilation was performed with the NuVasive NeuroVision system with triggered EMG hunting algorithms and fluoroscopic guidance gently spreading the fibers of the psoas muscle and docking on the left L3-4 disc annulus. A K wire was inserted into the left L3-4 disc annulus for stabilization. The Maxcess retractor also under triggered EMG and docked on the disc. This was also performed under fluoroscopic guidance. The lateral annulus was visualized. A hand-held EMG probe was utilized to confirm that no neurologic structures were within the surgical field. Microscopic magnification and microsurgical techniques were also utilized for hemostasis and to confirm that no neurologic structures were at risk.

    EXPLORATION OF LEFT LUMBAR PLEXUS: The left L3 nerve root was visualized and explored status-post discitis with extradiscal and foraminal extension resulting in radiculopathy. Neuroloysis of the left L3 nerve root and lumbar plexus was performed utilizing surgical microscopy and microsurgical techniques. At the the completion of the this portion of the procedure, the L3 nerve root and component of the lumbar plexus was free of further compression.

    ANTERIOR DISCECTOMY: An annulotomy was performed in the left lateral annulus followed by discectomy with pituitary rongeurs and Kerrison rongeurs. A sharp Cobb was utilized to elevate the cartilaginous endplates were well was left to them off of the cephalad aspect of L4 and the caudad aspect of L3. The remaining cartilaginous endplates were removed. There was no gross evidence of infection in this disc. Similarly, the bone was of good quality. Ring curettes and rasps were utilized to prepare the endplates with healthy bleeding bone.BONE MARROW HARVEST: 10cc of bone marrow was harvested from S1 utilizing a Jamshidi needle and syringe for autologous fusion purposes.

    ILIAC CREST BONE MARROW HARVEST: A Jamshidi needle was inserted through a separate fascial incision and separate skin incision into the left posterior superior iliac spine. 5 cc of bone marrow was aspirated in order to combine with of ethos tricalcium phosphate allograft for fusion purposes.

    ANTERIOR LUMBAR INTERBODY FUSION: An appropriate-sized NuVasive titanium cage was chosen with a 55 mm x 22 mm lordotic footprint 8mm cage chosen. This was filled with a combination of local autogenous bone graft saved from the endplate shavings, allograft with bone marrow aspirate and extra small infuse. The cage was then inserted under fluoroscopic guidance. Excellent distraction and fit was noted.

    Hemostasis was confirmed and the retractor was removed.

    CLOSURE: Copious irrigation was performed. The transversalis fascia was closed with 0 strata fix PDS suture, the transversalis musculature, internal oblique and external oblique were all reapproximated with 0 Vicryl suture. The subcutaneous tissue and lumbar fascia were closed with 2-0 Vicryl suture. The skin was closed with 4-0 Monocryl suture. Dermabond and Steri-Strips were applied. A sterile Bioclusive dressing was applied.

    WOUND CLASSIFICATION: CLEAN.

    SPECIMENS: NONE.

    COMPLICATIONS: NONE.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8460

    Your experience is not unusual. A retroperitoneal approach can commonly cause an ileus, This is where the intestines “go on strike” which causes abdominal discomfort, bloating, nausea, lack of passing gas and swelling of the belly. This can last for 2-4 days and food intake needs to be restricted. This will pass. Did you have a posterior instrumentation?

    Dr. Corenman

    jayd10033
    Participant
    Post count: 69

    Thanks doctor, I guess I didn’t copy the whole thing. Below is the Posterior work:

    POSTERIOR SPINAL FUSION: Utilizing the retractor blades, the left L3 and L4 medial transverse processes, L3 pars, and the lateral aspect of the left L3-4 facet joint were identified. The posterolateral bony elements were denuded with electrocautery and then decorticated utilizing aggressive currettage. The space was packed with local autogenous bone graft and additional Vitoss with bone marrow aspirate in order to perform posterior spinal fusion posterolaterally at the facet.

    POSTERIOR INSTRUMENTATION: A 55 mm rods was placed. Set screws were placed and then finally tightened utilizing torque-limiting screwdriver. The entire construct was then visualized utilizing fluoroscopic imaging in both AP and lateral views and noted to be in appropriate location. In this manner, posterior non-segmental instrumentation was performed.

    CLOSURE: Copious irrigation was performed. The fascia was closed with #0 Stratafix suture. The subcutaneous tissue was closed with 2-0 Vicryl suture. The skin was closed with 4-0 Monocryl Stratafix suture. Dermabond and Steri-Strips were applied. Marcaine 0.25% was injected. Sterile bi-occlusive dressings were applied.

    jayd10033
    Participant
    Post count: 69

    Today I was able to pass gas, and have a very small, mostly liquid BM, but continue to feel bloated. I have not restricted eating (though I am eating much less) — perhaps I should.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8460

    You are on the right track. Passing gas is a good indicator of clearing the ileus. As long as you limit your intake for now, you should be fine.

    Dr. Corenman

    jayd10033
    Participant
    Post count: 69

    Thanks. The incision is very painful, and any use of my abdominal muscles is as well, which makes it impossible to easily pass a BM. Taking Miralax and Senna and hoping it improves over the next few days.

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