PREOPERATIVE DIAGNOSIS: C6-7 disk herniation with radiculopathy, right.

POSTOPERATIVE DIAGNOSIS: C6-7 disk herniation with radiculopathy, right.

OPERATION PERFORMED: Anterior cervical decompression with partial vertebrectomy and fusion, C6-7, using right iliac bone graft and Eagle plating.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA

ANESTHESIA: General.

DRAINS: None.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 20 mL.

DESCRIPTION OF OPERATION: Under general anesthesia, the patient was positioned supine for anterior cervical decompression with partial vertebrectomy and fusion. Following padding of all bony prominences and routine preparation and draping, Dr. Doe provided an anterior approach to the cervical spine at C6-7. Once the levels had been confirmed radiographically, the procedure was undertaken. The annulus fibrosus was incised from one joint of Luschka to the other and removed piecemeal with a small rongeur. The anterior osteophytes were now taken down using a small rongeur as well. Bone wax was applied. The disk material was partially evacuated using a pituitary rongeur to decompress the disk at this point.

Once this had been accomplished, the Caspar system was introduced. Drill holes were made in the midline at C6 and C7 and Caspar screws applied. A Caspar distractor was applied over the screws and the interspace distracted. Using pituitary rongeurs and curettes, the interspace was now totally clean. The dissection was carried back to the PLL. There was some degree of osteophytic overgrowth posteriorly. Once all disk material and cartilaginous endplates had been taken down, a Midas-Rex was used to create a partial vertebrectomy. This was done using an AM-8 attachment. Once this was done, it was relatively straightforward to remove the PLL. By so doing, it was impossible to get further osteophytes removed posteriorly and to remove the disk material from the preforaminal area in the right posterior aspect of the interspace.

Once the canal had been decompressed using small pituitary rongeurs and angled curettes, the sclerotic bony endplates were taken down using a Caspar bur. Punctate bleeding bone was obtained. At this point, a separate incision was made over the wing of the right ilium. The dissection was carried down onto the ilium and the ilium was cleared on the inner and outer tables. Using a 7 mm parallel oscillating saw, a bone graft was obtained. This graft was now fashioned into a trapezoidal shape and fit into the interspace with a very slight interference fit.

Once this had been done, the Caspar system was removed with wax being applied over the holes created by the Caspar screws. A 14 mm Eagle plate was now obtained. The plate was bent to provide cervical lordosis and attached to the anterior cervical spine by means of four screws, two in each vertebra. Once the plate and screw had been placed, permanent x-rays were obtained which showed very good position of the plate and screws as well as the graft. As a result, at this point, final tightening of the screws was undertaken.

The wound was irrigated with antibiotic saline and an inspection was made. There was no excess bleeding. Likewise, the bone graft donor site was irrigated and Avitene applied. Both wounds were then closed in layers. A dry sterile dressing was applied over the iliac bone graft donor site and Dermabond was used on the skin of the neck. At this point, the patient was placed in a soft collar and transferred to the recovery room in good condition.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Chiari I malformation.

POSTOPERATIVE DIAGNOSIS: Chiari I malformation.

OPERATIONS PERFORMED:
1. Suboccipital craniectomy.
2. C1 laminectomy and C2 laminectomy with placement of dural expansion graft.

SURGEON: John Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. She was then placed in a Mayfield headrest and positioned in a prone fashion on gel rolls. All bony prominences were inspected and padded prior to sterile draping. The suboccipital and posterior cervical area were then prepped and draped in the usual sterile fashion.

Using a 15 blade knife, the skin was incised in the midline and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect paraspinal muscles laterally exposing the suboccipital bone in the C1 and C2 lamina. A Leksell rongeur was then used to remove the C1 and C2 lamina, and Midas Rex drill was used to create a suboccipital craniectomy. The underlying dura was then freed from the hypertrophic transverse bands. A 15 blade knife was used to incise the dura in the midline, and an elliptical dural expansion graft made from bovine pericardium was sutured in place. The 4-0 Nurolon sutures were used to secure the graft. A watertight closure was verified with the Valsalva maneuver. The expansion graft was then reinforced with 5 mL of sprayed on Tisseel.

The wound was copiously irrigated with antibiotic solution. The fascia was then reapproximated in a watertight fashion using interrupted 0 Vicryl sutures. Interrupted 3-0 Vicryl sutures were then used to reapproximate the subcuticular layer, and staples were placed in the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

Neurosurgery Operative Sample Report #2

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Right-sided L4-5 synovial cyst.
2. L4-5 grade I spondylolisthesis.
3. Bilateral facet arthropathy at L4-5.
4. Lumbar spinal stenosis secondary to all the above.

POSTOPERATIVE DIAGNOSES:
1. Right-sided L4-5 synovial cyst.
2. L4-5 grade I spondylolisthesis.
3. Bilateral facet arthropathy at L4-5.
4. Lumbar spinal stenosis secondary to all the above.

OPERATIONS PERFORMED:
1. Right-sided L4-L5 hemilaminotomy, partial medial facetectomy, and excision of synovial cyst.
2. Microdissection using operating room microscope.

SURGEON: John Doe, MD

ANESTHESIA: General.

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who was injured at the workplace. He was diagnosed with worsening of a L4-5 synovial cyst. He experienced severe radiculopathy secondary to this. Having failed conservative interventions, the patient elected to proceed ahead with surgical option of excision of the synovial cyst.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Wilson frame. All bony prominences were inspected and padded prior to sterile draping. The lumbosacral area was then prepped and draped in the usual sterile fashion.

Using a #15 blade knife, the skin was incised in the midline and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect the paraspinal muscles laterally exposing the L4-5 interspace on the right side. Self-retaining Taylor retractor was placed, and lateral fluoroscopic imaging was then used to confirm proper localization.

We then brought the microscope into the field and used this to assist with performing a microsurgical hemilaminotomy at L4 and L5 and a partial medial facetectomy. The Midas Rex drill was used to bur down a small portion of the L4 and L5 hemilamina and the medial portion of the facet. We soon uncovered a large synovial cyst, which had evidence of hemorrhage within it, which would have occurred during his workplace accident. This also would have accounted for the sudden onset of his symptoms. The synovial cyst was completely released from the underlying dura with a micro nerve hook and removed completely decompressing the exiting L5 and L4 nerve roots.

Excellent decompression was achieved. The wound was irrigated with antibiotic solution. A small amount of Duramorph paste was placed in the epidural space for analgesia and 0.5% Marcaine in the subcutaneous tissues. The fascia was then reapproximated with interrupted 0 Vicryl sutures and subcuticular layer with interrupted 3-0 Vicryl sutures. A Dermabond dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

Neurosurgery Operative Sample Report #3

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Unstable L1 burst fracture.

POSTOPERATIVE DIAGNOSIS: Unstable L1 burst fracture.

OPERATIONS PERFORMED:
1. Posterior open reduction of L1 burst fracture.
2. Placement of Synthes Schanz-type pedicle screws and rods from T12 through L2 nonsegmentally.
3. Posterior thoracolumbar arthrodesis from T12-L1 through L1-L2 using locally harvested morselized corticocancellous autograft bone and bone morphogenic protein-soaked sponges.

SURGEON: John Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Jackson table. All bony prominences were inspected and padded prior to sterile draping.

Using a 15 blade knife, the skin was incised in the midline and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect paraspinal muscles laterally exposing the posterior elements from T12 through L2. Lateral fluoroscopic imaging was then used to place Synthes Schanz-type pedicle screws into the pedicles of T12 and L2 bilaterally. Excellent fixation was achieved.

The rod was then connected to the implanted pedicle screws and a two-stage reduction maneuver was performed. The fracture was distracted and then lordosed. This resulted in excellent restoration of vertebral body height, restoration of lordosis, and apparent reduction of the retropulsed fragment. The wound was then copiously irrigated with antibiotic solution. Two crosslinks were applied. The facets at T12-L1 and L1-L2 were then heavily decorticated exposing cancellous bone for fusion. The four facets were then packed with bone morphogenic protein-soaked sponges and morselized corticocancellous autograft bone.

A subfascial Hemovac drain was placed, and the fascia was then reapproximated using interrupted 0 Vicryl sutures. Interrupted 2-0 Vicryl sutures were placed in the subcuticular layer and staples on the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

Neurosurgery Operative Sample Report #4

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Meningeal carcinomatosis.

POSTOPERATIVE DIAGNOSIS: Meningeal carcinomatosis.

PROCEDURES PERFORMED:
1. Placement of right frontal Ommaya reservoir.
2. Administration of 12 mg of intrathecal methotrexate.

SURGEON: John Doe, MD

ANESTHESIA: General.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman with a history of cancer who now presents with diagnosis of meningeal carcinomatosis. It was requested by the Hematology-Oncology service that an Ommaya reservoir be placed. Understanding all the risks and benefits of surgery, the patient elected to proceed with placement of an Ommaya reservoir.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed under general anesthesia. She was then placed supine on the operating room table. The right frontal area was then prepped and draped in the usual sterile fashion.

A horseshoe-shaped incision was created over Kocher’s point on the right side. A Midas Rex drill was then used to create a single entry bur hole at Kocher’s point. A ventricular catheter was then placed perpendicular to the skull entry bur hole and CSF was obtained at a depth of 5 cm. Clear colorless CSF was obtained; 15 mL of fluid was collected and sent for standard laboratory studies. An Ommaya reservoir was then connected to the catheter. The catheter length was set at 6.5 cm. Excellent CSF flow was achieved. Methotrexate 12 mg was injected into the catheter, administering the first dose of methotrexate.

The wound was then copiously irrigated with antibiotic solution and closed in the usual fashion using interrupted 0 Vicryl sutures in the galea followed by staples in the skin. A sterile dressing consisting of antibiotic ointment was then placed over the incision. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Lumbar radiculopathy.
2. Lumbar spondylosis.

POSTOPERATIVE DIAGNOSES:
1. Lumbar radiculopathy.
2. Lumbar spondylosis.

PROCEDURE PERFORMED: L4-5 and L5-S1 decompressive laminectomy with bilateral foraminotomies.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, intubated, and placed under general endotracheal anesthesia. She was turned prone on a Wilson frame, which was maintained in its lowest position.

The patient’s back was prepped and draped in a sterile fashion. The previous incision was identified and outlined and infiltrated with Marcaine with epinephrine. The incision was opened to the lumbar fascia. The self-retaining retractors were placed. Paraspinal muscles were taken down bilaterally in a subperiosteal fashion using the Harmonic scalpel. There was some more scar tissue on the right but the process of L4 and L5 resected. Interestingly, the patient was narrowed on the left as well and actually also had narrowed foramen.

Attention was first directed to the right. The L5 foramen was actually narrowed but also the S1 root was extremely compressed, mainly from scar formation and also from thecal sac compression. She did not appear to have a herniated disk but had a very large spur underneath, which actually went significantly even over to the left side and that side was resected as well and actually the S1 root was significantly compromised also. Therefore, foraminotomy was also performed on that side. The L4-5 disk was slightly bulging but not herniated.

At L5-S1, we did examine the disk area. Again, really no herniation per se was identified. There was some disk material that was identified. However, primarily the bulge appeared to be a very large central spur. Again, by doing a decompression and foraminotomies, there will be hopefully significant room for the roots to get through as well as thecal sac without further compromising. The scar tissue was identified as stated, primarily on the right. This was also resected.

At the completion of the procedure, thecal sac and nerve roots bilaterally were both decompressed. Hemostasis was achieved with bipolar electrocautery in a manner using Gelfoam soaked in thrombin.

The wound was irrigated and noted to be clear. The wound was then closed in layers, 0-Vicryl used to reapproximate the muscle and fascia layer, 2-0 Vicryl to reapproximate the subcutaneous layer in inverted, interrupted fashion, and 3-0 nylon to reapproximate the skin edges in an interrupted fashion.

PREOPERATIVE DIAGNOSIS: Left L5-S1 disk herniation.

POSTOPERATIVE DIAGNOSIS: Left L5-S1 disk herniation.

OPERATION PERFORMED: Left L5-S1 microdiskectomy.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ESTIMATED BLOOD LOSS: Less than 20 mL.

COMPLICATIONS: None.

SPECIMENS: None.

HISTORY: The patient has a left-sided L5-S1 disk herniation with mass effect on the left S1 nerve root. The patient was brought in for a left L5-S1 microdiskectomy.

DESCRIPTION OF OPERATION: The patient was brought to the operating room where general endotracheal anesthesia was induced. He was positioned prone, and the lumbar skin was prepped with Betadine. The C-arm fluoroscopy was used to localize the trajectory from the skin aiming towards L5-S1 interspace from approximately 3 cm lateral to the midline.

When the trajectory was confirmed on AP and lateral fluoro images, the skin incision was made as a parasagittal linear incision measuring about 2.5 cm. The incision was then infiltrated with 0.5% Marcaine with 1:200,000 dilution epinephrine and the dilating tubes were passed. A 5 cm METRx self-retaining retractor was used to maintain exposure. The overlying muscle was removed, and the inferior lamina of L5 was thinned with a high-speed drill. Under the operating microscope, a series of rongeurs were used to remove the inferior L5 lamina. The ligamentum flavum and underlying periosteum were removed. The epidural fat was removed, and the dura of the thecal sac and S1 nerve root sheath were exposed.

Under the operating microscope, the nerve root sheath was retracted medially, and there was a large subligamentous disk herniation noted to be compressing the left S1 nerve root. A tiny hole was made in the posterior longitudinal ligament exposing the herniated disk. Pituitary grasping forceps was used to remove the herniated disk, and there was no longer any compression of the left S1 nerve root. The field was irrigated with bacitracin solution and Gelfoam was placed in the epidural space. The muscle was then infiltrated with 0.5% Marcaine with 1:200,000 dilution of epinephrine.

The muscle was closed with interrupted 3-0 Vicryl suture. The dermis was closed with interrupted 3-0 Vicryl suture. The skin edge was closed with running 4-0 Monocryl subcuticular suture. Dermabond was applied to the wound, and the patient was returned into the supine position, extubated, and transferred to the recovery room in stable condition. Sponge and needle counts were correct at the end of the procedure.

PREOPERATIVE DIAGNOSES:
1.  Left L5-S1 herniated nucleus pulposus.
2.  Morbid obesity.

POSTOPERATIVE DIAGNOSES:
1.  Left L5-S1 herniated nucleus pulposus.
2.  Morbid obesity.

OPERATION PERFORMED:  Left L5-S1 microdiskectomy.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

OPERATIVE FINDINGS:  Herniated nucleus pulposus.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  70 mL.

DESCRIPTION OF OPERATION:  The patient was seen in the preoperative holding area, and the surgical site was marked. After successful induction of general endotracheal anesthesia, the patient was placed on the Andrews table. The patient’s orbits, peripheral nerves, and bony prominences were padded and protected. The back was then prepped and draped in the usual sterile fashion. The patient was administered 2 g of Ancef prior to the incision. Safe time-out was performed.

A left L5-S1 paraspinal exposure was performed. An extra system was used throughout the case due to the deep nature of the incision and extra need for retraction. The skin was incised with a scalpel, and dissection was carried out with electrocautery. Another radiograph was obtained to confirm the L5-S1 interlaminar space prior to proceeding with the laminar foraminotomy.

High-speed bur was used to take down the leading edge of L5. Ligamentum flavum was released. Decompression was carried out to the medial wall of the left S1 pedicle. The patient was found to have a large extruded disk fragment. This was carefully mobilized from the thecal sac and nerve. Nerve root retractor was placed, and the disk herniation was removed.

With the diskectomy completed, the disk space was irrigated and free fragments were removed. We did have to use extra long retractors throughout the case to enable us to safely work within the spine. With the decompression and diskectomy completed, attention was turned to closure.

All bleeders were controlled using bipolar cautery. At the time of closure, the wound was copiously irrigated. The wound was closed in layers with interrupted 0 Vicryl in the fascia and 2-0 for the subcutaneous tissue. Subcutaneous tissue was injected with Marcaine. The skin was closed with 3-0 Monocryl and Steri-Strips. A sterile dressing was applied. The patient was awoken from anesthesia and transferred to the PACU in stable condition. All counts were correct x2 at the end of the procedure.

PREOPERATIVE DIAGNOSIS: L1 epidural mass.

POSTOPERATIVE DIAGNOSIS: Extruded disk at L1.

OPERATION PERFORMED:
1. L1 laminectomy and excision of extruded disk.
2. Intraoperative ultrasound.
3. Microdissection.
4. Use of intraoperative fluoroscopy, less than 1 hour.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, PA-C

ANESTHESIA: Local.

INDICATIONS FOR OPERATION: This is a (XX)-year-old female who did lifting and twisting while at work. She developed pain as well as weakness and numbness in the lower extremities. This was also associated with bowel and bladder dysfunction. An MRI demonstrated a large central epidural mass at L1 with severe conus medullaris compression, most consistent with an extruded disk fragment.

DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room. General anesthesia was administered. The patient was placed in the prone position on a Wilson frame, which was flexed. The lumbar area was prepped and draped sterilely. Local anesthetic was administered subcutaneously. Localizing needles were placed to identify the L1 level with intraoperative fluoroscopy.

A midline incision was made over the L1 level. The paraspinal muscles were stripped off the spinous process and lamina of L1. The spinous process of L1 was then removed using a rongeur. At this point, the operative microscope was brought into use, and the remainder of the procedure was performed using careful microdissection technique, including the use of microbipolar cautery, microscissors and microdissectors. This was done to prevent injury to the delicate neurovascular structures.

The lamina of L1 was thinned using the high-speed drill, and laminectomy was completed using Kerrison rongeurs. Dissection was continued laterally to expose the lateral thecal sac bilaterally. The exiting L1 nerve root was identified bilaterally. The thecal sac was then retracted medially, both above and below the L1 nerve, and the epidural mass could not be definitively palpated from either side.

Therefore, the level again was checked and again was confirmed to be the L1 level, and intraoperative x-ray was also obtained. Not being able to definitively palpate the lesion, an ultrasound was obtained, which did demonstrate the lesion at L1. On MRI imaging, this appeared to be an extradural mass, but because of its central location and difficulty of retraction of the thecal sac, it was not easily exposed. This was also the level where the conus medullaris was present, and therefore, excessive traction was not warranted. Because of this, it was felt that a transdural approach was necessary to gain exposure.

Therefore, a midline durotomy was made using a 15 blade, using microdissection techniques. The dura was opened in the midline. The arachnoid was sharply dissected. This afforded exposure of the conus medullaris and the exiting nerve roots of the cauda equina. With careful microdissection techniques, the posterior portion of the thecal sac was inspected. There was a protruding mass, which was extradural.

Therefore, the anterior dura was incised and disk material was encountered. This was sent for pathologic evaluation. Using microdissection techniques, large fragments of disk were able to be removed in this fashion. Exposure was performed on both sides, and no further disk material was removed.

The area was irrigated with excellent hemostasis. The conus medullaris and the exiting nerve roots were well protected. The dura was then closed with 4-0 silk suture. Tisseel was placed on the durotomy site. Gelfoam was placed in the lateral gutters and additional Tisseel was applied. The incision was closed with multiple layers of Vicryl suture. The skin was closed with a running nylon suture and dressed sterilely.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Hydrocephalus.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old woman. The patient over several weeks noticed intermittent episodes of progressive memory loss and confusion. The patient thinks that her short-term memory is more affected. Currently, she denies any confusion and thinks that her mentation is normal. She denies any headache. She denies any visual disturbances. She denies any nausea or vomiting. She does admit to somewhat unsteady and clumsy gait. There is no history of bowel or urinary incontinence. A CT of the brain is suggestive for communicating hydrocephalus.

PAST MEDICAL HISTORY: Remarkable for esophageal carcinoma and breast CA.

PAST SURGICAL HISTORY: She underwent an esophagectomy.

MEDICATIONS: Lipitor.

PHYSICAL EXAMINATION: Neurologic Examination: Overall nonfocal. The patient is awake and alert with a very pleasant affect. She is eloquent, and her speech is fluent. She is oriented x3. Her mentation appears to be normal. Cranial nerve examination II through XII normal. Pupils are equal and reactive to light and accommodation. Extraocular movements are intact. There is no nystagmus. The face is symmetric. Remaining cranial nerves are normal. Extraocular range of motion is normal. There is no nuchal rigidity. Motor strength is 5/5 throughout. There is no upper extremity drift. Her muscle tone is normal. Deep tendon reflexes are hypo to normoactive. There are no pathologic reflexes. There are no long tract signs. Sensory examination is intact to light touch and proprioception. Her gait is slightly wide based and shuffling. She has mild dyskinesia when trying to tandem gait.

DIAGNOSTIC DATA: A CT of the brain reveals enlarged lateral and third ventricle with transependymal edema.

ASSESSMENT AND PLAN: The patient’s presentation and radiologic abnormalities are consistent with communicating hydrocephalus. Currently, she is neurologically stable. We will obtain an MRI of the brain with and without contrast, especially in view of her previous history of breast and esophageal CA. Depending on the findings, she might benefit from intervention with shunting procedure.

PREOPERATIVE DIAGNOSIS: Lumbar canal stenosis.

POSTOPERATIVE DIAGNOSIS: Lumbar canal stenosis.

OPERATIONS PERFORMED:
1.  Left iliac bone marrow aspirate.
2.  Bilateral L3 and L4 laminectomies with foraminotomies at L2-L3, L3-L4, and L4-L5 bilaterally.
3.  L3-L4 and L4-L5 posterior fusion without instrumentation using structural bone graft and bone marrow aspirates.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

BLOOD LOSS: 500 mL.

FLUIDS: 1150 mL.

URINE OUTPUT: 250 mL.

DRAINS: One Hemovac drain.

SPECIMENS: No specimens.

OPERATIVE FINDINGS: Lumbar canal stenosis at L2-L3, L3-L4, and L4-L5, worst on the right L3-L4 and L4-L5.

COMPLICATIONS: None.

INDICATION FOR OPERATION: The patient is a (XX)-year-old female who is still very active and very cognitively aware. She still travels extensively and has been finding difficulty with her gait as well as severe neuralgic pain in her right leg. This has diminished her quality of life, and despite all reservations about her age, she wanted to go ahead with a surgical decompression. MRI identified lumbar canal stenosis at the L2-L3, L3-L4, and L4-L5 levels.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general endotracheal anesthesia. She was turned prone onto the Jackson radiolucent spinal table, and preoperative x-rays with spinal needles were taken to confirm the projection at L3, L4, and L5. The area was then prepped and draped in a sterile fashion.

We then made an incision over the spinous processes of L3, L4, and L5 in the midline approximately 4 inches. Bipolar cautery was used to obtain hemostasis, and we placed self-retaining retractors in the wound. We then used the monopolar cautery to perform a subperiosteal dissection of the paraspinal muscles down to the level of the lamina. The retractors were positioned deeper in the wound. We used x-rays again to confirm the position at L3, L4, and L5.

At this point, we used the Leksell rongeur to remove the spinous processes of L3 and L4 and then used a 4 mm and later the 5 mm cutting bur with the Midas Rex high-speed drill to perform bilateral laminectomies at L3 and L4. We then used smaller Kerrison rongeurs and suction to perform bilateral foraminotomies at L2-L3, L3-L4, and L4-L5.

The worst stenosis was found on the right at L3-L4 and L4-L5. There were no spinal fluid leaks. A large amount of thick and hypertrophic ligamentum flavum and hypertrophic facet joints were found causing the stenosis. At this point, we irrigated the wound with antibiotic solution and placed large pledgets of Gelfoam over the thecal sac to prevent future scarring.

We then turned our attention to the fusion. We aspirated about 20 mL of bone marrow from the left posterior iliac spine. We mixed this with Healos structural bone graft as well as DBM allograft. We then used a 5 mm cutting bur to decorticate the facets as well as the lateral aspects of L3, L4, and L5. The Healos, the bone marrow, and the allograft were then placed as only grafts over those two levels and a two-level fusion performed from L3-L4 and L4-L5.

At this point, we once again checked for hemostasis and irrigated the wound with antibiotic solution. We closed the dorsal fascia with interrupted 0 Ethibond sutures and the subdermal tissues with interrupted 2-0 Vicryl sutures. Finally, the skin was closed with a running subcuticular 4-0 Monocryl, and Steri-Strips were placed with a sterile dressing and fixed the drain into place. The patient was turned, returned to the supine position on a regular bed, and transferred to the PACU for further recovery. There were no complications.

PREOPERATIVE DIAGNOSIS: Suprasellar mass.

POSTOPERATIVE DIAGNOSIS: Suprasellar mass.

OPERATION PERFORMED: Right transorbital frontal craniotomy and removal of the suprasellar lesion.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

COMPLICATIONS: None.

SPECIMEN: Suprasellar mass.

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman who presented to the hospital a few days ago with onset of acute headaches for a few days and was found to have suprasellar mass and also some spots of subarachnoid hemorrhages. The patient was investigated with cerebral angiogram and MRI, which confirmed the presence of the subarachnoid hemorrhage and also the presence of the suprasellar lesion indenting the optic nerves and the optic chiasm.

After a long discussion with the patient, we decided to proceed with biopsy of the lesion and possible removal. The patient understands the risks and benefits including, but not limited to, stroke, hematoma, reoperation, infections, blindness, and seizures. The patient signed consent to proceed with right transorbital frontal craniotomy and removal of the suprasellar lesion.

DESCRIPTION OF OPERATION: The patient was intubated and placed in the supine position. Then, a frontal temporal scalp incision was marked. It was prepped and draped in a sterile fashion. Incision was made with 10 blade scalpel and Bovie coagulator. The scalp flap was reflected anteriorly and inferiorly.

Then, using Midas Rex and after dissection of the temporalis muscle, a bur hole was made in a lateral frontal area and a small flap was turned, which included also the rim of the orbit. In this fashion, we obtained a skull base approach of the anterior fossa.

The dura was opened, and under the microscope with microdissection and with the help of a Budde retractor, the frontal lobe was gently retracted. CSF was removed, and the anterior fossa was approached. After cutting the arachnoid along the optic nerve, the carotid, and optic chiasm, the lesion was immediately found. The lesion was entered. After coagulation, it was removed in a piecemeal fashion. The pieces were sent to pathology for examination. The capsule was emptied.

Hemostasis was easily achieved. The area was abundantly irrigated with warm lactated Ringer. At the end of the surgery, the dura was closed with 4-0 Vicryl. The bone flap was replaced and affixed with a miniplate and then some of the bony defects were also covered with DBX bone source. The scalp was then closed with 2-0 Vicryl and staples.

PREOPERATIVE DIAGNOSES:
1. Cervicalgia.
2. Bilateral shoulder pain.
3. Left upper extremity pain.
4. Dynamic instability, C5-6.

POSTOPERATIVE DIAGNOSES:
1. Cervicalgia.
2. Bilateral shoulder pain.
3. Left upper extremity pain.
4. Dynamic instability, C5-6.

OPERATIONS PERFORMED:
1. Anterior cervical diskectomy and fusion, C5-6.
2. Partial vertebrectomy, C5, for decompression.
3. Use of tricortical iliac crest bone graft for fusion.
4. Use of anterior instrumentation over two to three vertebral segments.
5. Use of neuromonitoring of the spinal cord.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 15 mL.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION: After informed consent, the patient was taken to the operating room where general anesthesia was induced. She was placed supine on the operating table where pressure points and extremities were padded in the routine fashion. She was given routine preoperative prophylactic antibiotics, and neuromonitoring and anesthetic devices were attached. The time-out identified the operative site. The neck and left iliac crest were prepped and draped in a standard sterile fashion.

We started by making an incision from midline out to the left medial border of the sternocleidomastoid with the knife. We used Bovie cautery to dissect down the platysma. The platysma was divided. We then followed the plane along the medial border of the sternocleidomastoid down to the point between the carotid sheath and esophagus and trachea. We followed this down bluntly to the prevertebral fascia, which we cleared off with a Kittner elevator. We then placed a spinal needle in the C5-6 disk space and confirmed position with C-arm fluoroscopy. We then choked the internal longitudinal ligament and divided this out bilaterally at the longus colli with a Bovie. We then placed self-retaining retractor and had the anesthesiologist look down and reinflate the ET cuff after 5 seconds.

Following this, we had a 15-blade for annulotomy. We used pituitaries, curettes, and Kerrisons to continue diskectomy. We placed Caspar self-distraction pin and gently distracted the disk space. We then brought in a bur and burred down the inferior body of C5 down to the posterior vertebral body. There was some retrolisthesis at C5-6 and we again used the bur and burred down this posterior and inferior portion of C5.

Following this, we were then able to find the posterior longitudinal ligament and elevate this with a micro nerve hook. We then used 1 mm Kerrison and divided the PLL along its entirety out to the neural foramen where foraminotomies were performed. At this time, we were able to easily pass the medium size nerve hook without difficulty. We then continued to prepare the endplates with curettes as well as the bur until it was satisfactorily prepared. At that time, we filled the incision with copious irrigation.

We then turned our attention down to the left iliac crest. We made an incision over the iliac crest with a 15-blade. We then used the Bovie to dissect down over the iliac crest. We elevated the fascia using Bovie cautery off the inner and outer table and were able to protect this with a pair of elevators. We then used the 7 mm dual-blade reciprocating saw and harvested the iliac crest bone graft without difficulty. We then obtained hemostasis and used copious irrigation after doing this.

We were able to easily close the fascia using 0 Vicryl in a figure-of-eight fashion. We again copiously irrigated and closed the subcutaneous tissue with 2-0 Vicryl, interrupted fashion, followed by 3-0 Vicryl, interrupted fashion, and 4-0 Monocryl running subcuticular suture for the skin. Dermabond and Steri-Strips were applied followed by sterile dressing. Marcaine 0.5% was injected for analgesia. We then placed a sterile dressing without difficulty.

We turned our attention back to the neck. We continued to prepare the disk space with a rasp and we placed this iliac crest bone graft without difficulty. We then got a 12 mm plate held with provisional fixation pins. We then got AP and lateral fluoroscopy to confirm position. Following this, we placed 12 mm screws x2 at C5 and C6 without difficulty. We then were able to again obtain AP and lateral fluoroscopy to confirm this excellent position.

Following this, we tightened the screws completely. We then copiously irrigated and obtained excellent hemostasis. We closed the platysma using 2-0 Vicryl interrupted fashion. We again irrigated and closed subcutaneous tissue with 3-0 Vicryl interrupted fashion and 4-0 Monocryl running subcuticular stitch for the skin. Dermabond and Steri-Strips were applied followed by sterile dressing. The sponge and needle counts were correct x2. There was no change whatsoever on neuromonitoring at the spinal cord throughout this procedure. The patient was awakened and was taken to recovery in stable condition. The patient did have her rigid collar applied prior to leaving the operating room.