Apologies, I left out an entire operation!
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.