jayd10033
Participant
Post count: 78

Hi Doctor. I had the procedure today. Feeling pretty good for day 1. I don’t have any questions today but you asked to keep you posted, so here is the post-op report! Thank you so much for always being so generous with your analysis and guidance.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSES:
1. LEFT L5-S1 HERNIATED NUCLEUS PULPOSUS.
2. BILATERAL L5-S1 LATERAL RECESS STENOSIS.
3. BILATERAL L5-S1 LUMBAR RADICULOPATHY.

POSTOPERATIVE DIAGNOSES:
1. LEFT L5-S1 HERNIATED NUCLEUS PULPOSUS.
2. BILATERAL L5-S1 LATERAL RECESS STENOSIS.
3. BILATERAL L5-S1 LUMBAR RADICULOPATHY.

OPERATIONS:
1. LEFT L5-S1 LAMINOTOMY AND DISKECTOMY.
2. RIGHT L5-S1 HEMILAMINECTOMY WITH PARTIAL MEDIAL FACETECTOMY.
3. USE OF INTRAOPERATIVE MICROSCOPE AND MICROSURGICAL
TECHNIQUES.
4. INTERPRETATION OF INTRAOPERATIVE FLUOROSCOPY.

ANESTHESIA: General

TYPE OF ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.

ESTIMATED BLOOD LOSS: MINIMAL.

HARDWARE: NONE.

DRAINS: NONE.

CONDITION: stable

FINDINGS: LEFT L5-S1 HERNIATED NUCLEUS PULPOSUS (PROTRUSION WITH IMPENDING EXTRUSION), BILATERAL LATERAL RECESS STENOSIS.

PROCEDURE IN DETAIL:

The patient was transported from the preoperative holding area to the operating suite where general anesthesia was administered by Department of Anesthesia. Sequential compression devices were placed on the bilateral calves for DVT prophylaxis. Perioperative intravenous antibiotics were administered.

POSITIONING: The patient was positioned prone on the Jackson table utilizing the Wilson frame 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 of the elbows.

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, radiographic localization in both AP and lateral planes utilizing fluoroscopy (interpreted intraoperatively by the surgeon), a 22-mm incision was made longitudinally in the midline over the L5-S1 interspace just to the left of midline. A left paracentral fascial incision was performed to the left of the L5 spinous process with electrocautery. Sequential tube dilation was the Medtronic METRx system until a 4 cm x 18 mm tube was docked on the left side on the L5 hemilamina. A marker was placed underneath the lamina and a cross-table fluoroscopic radiograph was taken confirming the appropriate level. This was interpreted intraoperatively by the surgeon. At this time, the operating microscope was brought in to the sterile field and microsurgical techniques were utilized for the remainder of the case.

LAMINOTOMY: A laminotomy was performed utilizing the motorized high-speed bur and completed with Kerrison rongeurs. The ligamentum flavum was resected at the L5-S1 interspace on the left side. At this time, the S1 nerve root was identified along with the thecal sac.

LEFT L5-S1 DISKECTOMY: The S1 nerve root and thecal sac were gently mobilized and protected with a nerve root retractor. A disc protrusion was identified underneath the medial aspect of the traversing S1 nerve root and the thecal sac. At the apex of the protrusion it appeared that and extrusion was imminent. A small transverse annulotomy was performed with a #15 blade scalpel. Gentle pressure was applied to either side of the annulotomy with the #8 suction and small straight ball-tipped probe and the disc herniation readily extruded through the annulotomy. The disc base was explored with a small ball-tipped probe as well as the micro pituitary rongeur and additional fragments were removed. A maximal amount of healthy disk material was maintained. The disk space itself was irrigated with antibiotic irrigation and any free and loose fragments were also removed. At the termination of the decompression, a long ball-tipped probe was utilized to palpate the ventral aspect of the thecal sac, the exiting L5 nerve root and traversing S1 nerve root. The traversing nerve root was noted to be gliding freely. Hemostasis was confirmed.

RIGHT L5-S1 HEMILAMINECTOMY WITH PARTIAL MEDIAL FACETECTOMY: The retractor tube was removed and then attention was turned to the right side. A second separate fascial incision was made to the right of midline and sequential tube dilation was performed until a 4 cm x 18 mm tube was placed clearly visualizing the right-sided hemilamina. A crosstable fluoroscopic radiograph was taken confirming the appropriate level with a Woodson elevator underneath the lamina. The operative microscope was brought into the sterile field again. Soft tissue was denuded from the right L5 lamina. A motorized high-speed bur was utilized to perform hemilaminectomy and partial medial facetectomy. This was completed with 3 mm 4 mm Kerrison rongeurs. The cephalad aspect of S1 was also decompressed and removed utilizing Kerrison rongeurs. At the termination of decompression the traversing right S1 nerve root and thecal sac were noted to be free of further compression. Hemostasis was confirmed. Then, 1 mL of 80 mg Depo-Medrol was instilled into the spinal canal as an epidural injection.

CLOSURE: The METRx tube was removed. The fascia was closed with #0 Stratafix suture bilaterally on both sides of the spinous process. The subcutaneous tissue was closed with 2-0 Vicryl suture. The skin was closed with 4-0 Monocryl Stratafix suture. Marcaine 0.25% was injected. Dermabond and Steri Strips were applied. A sterile bio-occlusive dressing was applied.

At the termination of the procedure, we were informed that all needle, sponge, and instrument counts were correct. The patient was turned supine and extubated by the Department of Anesthesia. The patient was noted to be moving bilateral lower extremities grossly. The patient was transported to the Postanesthesia Care unit in satisfactory condition, having tolerated the procedure well without incident or complications.

WOUND CLASSIFICATION: CLEAN.

SPECIMENS: NONE.

COMPLICATIONS: NONE.