DATE OF OPERATION: MM/DD/YYYY
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.
