EXAMPLE
Emeka Nchekwube, M.D.
DISCHARGE SUMMARY
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FINAL DIAGNOSES :
1. Status post anterior cervical diskectomy C3-C4, C4-C5,
C5-C6.
2. Anterior cervical microforaminotomy at C4, C5, C6.
3. Anterior cervical fusion using human allograft struts
C3-C4, C4-C5, C5-C6.
4. Anterior cervical internal stabilization with EBI anterior cervical plates and screws C3, C4, C5, ad C6.
5. Postoperative anterior cervical cerebrospinal fluid fistula.
OPERATION:
1. Removal of anterior cervical plates at C3, C4, C5, and C6.
2. Revision of anterior cervical fusion C4-C5, C5-C6.
3. Anterior cervical microsurgical repair of cerebrospinal fluid fistula C4-C5, C5-C6.
4. Revision of anterior cervical fusion at C4-C5, C5-C6.
5. Replacement of anterior cervical plates (EBI), C3, C4, C5,
C6.
HISTORY: The patient had a recent history of anterior cervical microsurgical diskectomy, foraminotomy, fusion, and internal stabilization for multilevel cervical disk herniation. The initial operation also revealed a dural laceration from the ruptured disk which retropulsed through the posterior longitudinal ligament into the subarachnoid space at C4-C5, and
C5-C6. During the work-up, cerebrospinal fluid leak was noted which was repaired at the initial operation. This repair held well for about two days following which the patient developed a
CSF fistula with cerebrospinal leakage through the Jackson-Pratt drain stab wound in the neck. This was not brought to my attention for several days. The patient was admitted emergently for intravenous antibiotic treatment and management of the fistula.
Treatment consisted of absolute bed rest and an attempt at postural repair of the fistula, which did not succeed. This was followed by an attempt at lumbar spinal drainage but the patient was deathly afraid of the needle and refused to have this done.
This left, finally, the option of direct surgical intervention, which was elected. An initial lumbar spinal drainage attempt, however, was unsuccessful due to the combination of the patient’s poor cooperation, needle phobia, and technical difficulties getting into the subarachnoid space.
Surgery was undertaken and during surgery, the original construct was taken down and the cerebrospinal fluid leak site was

identified by MRI study at C4-C5, and C5-C6. This area was explored under the microscope and the leaks identified and repaired with a combination of Gelfoam, Surgicel, and fibrin glue, followed by replacement of the graft at C4-C5, and C5-C6.
A new construct was placed from C3 to C6 using rescue screws for good engagement of the bones.
The patient had an uneventful postoperative course with no evidence of cerebrospinal fluid leak for two days. She was then discharged home today in a stable and satisfactory condition with instructions on spine hygiene and wound care. Wound healing was satisfactory at the time of discharge. Antibiotic treatment in the hospital included Rocephin, which resulted after two days in massive diarrhea due to Clostridium difficile overgrowth, and this responded to switch to vancomycin intravenously. The patient was kept on vancomycin the rest of her hospitalization.
At the time of discharge the patient was afebrile; her hemogram was within normal range. The patient will be seen and followed in the office in a week.
CONDITION UPON DISCHARGE : Stable and satisfactory.