DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Herniated lumbar disk, L3-4, on the central right, large.
POSTOPERATIVE DIAGNOSIS: Herniated lumbar disk, L3-4, on the central right, large.
PROCEDURES PERFORMED: Decompressive laminectomy, bilateral, L3-4; bilateral diskectomy, L3-4; and repair of small Dural tear, right side.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was given preoperative medication and brought to the operating room. He was given general anesthesia and intubated. Athrombic pumps were applied to both legs. A Foley catheter was inserted. The patient was placed on the operative table in a knee/chest position, utilizing the Andrews spinal frame. All bony prominences were padded. The head and neck were positioned by Anesthesia and checked frequently throughout the case. The perineum was isolated with a Steri-Drape. The back was then prepped with alcohol and DuraPrep and draped in the usual manner.
A midline incision was made centered over the L3-4 level. This was carried down to the deep fascia. All bleeding points were electrocoagulated. The deep fascia was incised and the paraspinal muscle elevated bilaterally. Hemostasis was attained. A tenaculum was placed in the spinous process of L3 and an x-ray was taken to confirm the level and location. The Collis retractor was used for exposure. The soft tissue was cleared from the L3-4 interspace level. The interspinous ligament at L3-4 was excised. The inferior two-thirds of L3 was excised, as was the superior one-third of the spinous process of L4. Eventually, all of the spinous process of L3 was removed. The Midas Rex AM-2 tool was used to begin the laminectomy in the midline at this level. The Midas Rex AM-8 tool was used to decompress over the lateral recess. Midline was identified and a small cottonoid was placed below this to protect the underlying dura.
The remainder of the laminectomy was performed using the various sizes of angled Kerrison rongeurs. Care was taken to decompress this carefully, as there was a very large central right disk herniation. Initially nerve roots were hypersensitive. The left side was decompressed followed by the right side. The underlying disks had significant compression on the nerve roots, surprisingly more on the left side than on the right side. The dura, nerve root was retracted medially, initially on the left side. A window was made in the annulus, and a diskectomy was then performed using straight, angled up and angled down pituitary rongeurs. The angled and Epstein curettes were used to help mobilize the disk material, especially medially.
Following this, the dura and nerve root on the right side were mobilized as well. However, there was marked adhesion of the dura to the underlying protruding disk on the right side. In the process of mobilizing the dura, a small tear developed along the right side of the dura. This was initially protected with cottonoid to allow the dura to be retracted further medially. The underlying disk was quite firm and protruding. A window was then made in the annulus and a diskectomy performed in a similar manner. The pituitary rongeurs and the curettes were used in a similar manner. Small epidural veins on the floor of the canal were cauterized with the bipolar electrocoagulation. Thrombin-soaked Gelfoam was utilized as well. All Gelfoam was removed by the end of the procedure.
The tear on the right side of the dura was then examined. This was repaired using Gore-Tex CV-6 sutures, interrupted. A watertight closure was achieved. The disk space was then irrigated with saline through a 14 gauge Angiocath to remove any remaining disk material and/or debris. The floor of the canal was rechecked. The hockey stick instrument was utilized and noted no impingement on the dura or nerve roots, out into the foramina, as well. The dura was then protected with several large cottonoids. The retractor was removed and the paraspinal tissues were irrigated with pulsatile lavage. Hemostasis of the paraspinal muscles was then completed.
The paraspinal tissues were then approximated using 0 Vicryl to initially close the dead space at the L3-4 level. A medium Hemovac drain was then placed deep to the fascia, which was approximated with 0 Vicryl interrupted. The subcutaneous tissues were again irrigated with pulsatile lavage and then closed in layers using 2-0 and 3-0 Vicryl, interrupted. A running 4-0 Monocryl suture was used in the subcuticular layer. Skin edges were sealed with Dermabond. The wound was cleansed and sterile Telfa pad and dressings were applied. The patient was then awakened from anesthesia and brought to the recovery room in satisfactory condition. Sponge and needle counts were correct.
