ASSISTANT:
ANESTHESIOLOGIST:
HAMDAN FAYAD, PA-C.
OPERATION:
1.
Decompressive right-sided hemilaminectomy, L5 and S1
(CPT 63047-59, 63048-59) with L5-S1 foraminotomy
(separately identifiable procedure).
2.
Segmental type posterior instrumentation (two
segments) (CPT 22840).
3.
Posterior spinal fusion L5-S1 (CPT 22612).
4.
Transforaminal lumbar interbody fusion (fusion of the
anterior column of the spine through a posterior/right
transforaminal approach) (CPT 22630).
5.
Placement of Leopard Carbon fiber Peek interbody cage,
L5-S1 (CPT 22851).
6.
Harvest of left iliac crest bone graft through
separate skin and fascial incision (CPT 20937).
7.
One hour of intraoperative fluoroscopic time (CPT
76000-26).
PREOPERATIVE DIAGNOSES:
1.
Grade I isthmic spondylolisthesis L5-S1.
2.
Neural foraminal spinal stenosis, right side, L5-S1,
severe.
3.
Degenerative disk disease, L5-S1.
4.
Hypertension (concurrent comorbidity).
POSTOPERATIVE DIAGNOSES:
1.
Grade I isthmic spondylolisthesis L5-S1.
2.
Neural foraminal spinal stenosis, right side, L5-S1,
severe.
3.
Degenerative disk disease, L5-S1.
4.
Hypertension (concurrent comorbidity).
COMPLICATIONS:
None apparent.
ESTIMATED BLOOD LOSS:
450 cc.
CONDITION ON TRANSFER TO PACU:
OPERATIVE TIME:
Stable.
(Skin to skin) 4 hours 45 minutes.
INDICATION: The patient is a pleasant, cooperative
73-year-old gentleman who has had left buttock and lower
extremity pain for the last 15 to 20 years with some degree
of intermittent low back pain. His symptoms have been
quite pronounced in the left buttock and lower extremity in
the last several months to two years that has failed to
respond to conservative care. His diagnosis has been
confirmed by imaging studies (C-plane from radiography and
MRI). It was felt, therefore, that the above-noted
procedure was indicated.
PROCEDURE: After induction of the anesthetic and placement
of a Foley catheter and all appropriate IVs, the patient
was turned into a prone position on a Jackson table and had
his lumbar spine prepped and draped in the usual sterile
fashion. C-arm fluoroscopy was brought in and the
trajectory of the pedicle screws marked out on the skin.
Initially it had been planned to do this through a
percutaneous minimal invasive approach.
An incision was made to the left side of the midline in
line with this trajectory approximately 3 cm long just
superior to the posterior superior iliac spine.
Unfortunately the appropriate retractors were not noted,
and despite the fascial dissection and palpation of the
appropriate landmarks, it was not felt that we could
satisfactorily proceed with this type approach. Therefore,
a standard midline incision was made and the posterior
spine exposed in a standard fashion subperiosteally just
lateral to the facet joints.
The pedicles of L4 and L5 and S1 were probed and pedicle
screws placed in standard fashion using biplane or C-arm
fluoroscopy. The type of screws for this were the Laguna
screws from the Allez spine instrumentation set. The
pedicles were tapped, 45-mm length screws were placed, and
EMG threshold testing performed indicating screw safety at
all but the left S1 screw. This screw was removed and
although the hole was palpated, not found to have any
defects, it did appear to be slightly medial on the C-arm
fluoroscopy and, therefore, most likely a thread or two had
cut through the pedicle, resulting in this subthreshold EMG
of 5 mA. Therefore, the screw hole was removed laterally
by 0.5 to 1 cm, and the screw placed lateralized slightly.
The screw was replaced and its threshold testing
demonstrates screw safety at 10 mA. The AP and lateral
fluoroscopy confirmed good alignment of the screws.
A 40-mm rod was placed in the saddles of the screw on the
patient's left side, distraction applied. A decompressive
laminectomy was carried out of the right side of the L5
lamina (right side hemilaminectomy), and left cephalad S1
lamina sufficient to completely decompress the S1 and
traversing S1 and the exiting L5 nerve roots. This was the
separately identifiable decompression part of the
procedure, and this part of the procedure indicated that
the nerve roots were free and the decompression had been
satisfactorily completed.
Attention was directed to the left iliac crest through the
same incision that had been used to initially place the
screw trajectory, the posterior superior iliac spine was
removed and osteotomized and copious cancellous bone
curetted from between the tables. Crushed cancellous bone
was used to reconstruct the iliac crest. Some
demineralized bone matrix as well was used. The wound was
then closed in layers with running #1 Vicryl suture
ultimately and the skin closed with interrupted
subcutaneous #2-0 Vicryl suture and then staples for the
skin. This was for the lateral wound.
Now the approach was made for the interbody fusion that was
separately identifiable from that of the decompression.
The annulus fibrosis was removed. After the annulotomy was
carried out, the disk space was curetted and prepared to
accept the Leopard cage. The spinous process of L5 was
removed and morcellized as well. Local laminectomy bone as
well as spinous process bone and celiac crest bone was
placed anterior in the inner space followed by the Leopard
cage that had been packed with iliac crest bone, followed
by more iliac crest bone posterior to the cage in a
cantilever fashion. The cage was palpated and found to be
in good alignment and C-arm fluoroscopy indicated good
alignment of the cage.
Compression was applied to the rod on the left side, a
40 mm rod on the right side was placed and screw caps
tightened and secured to the appropriate torque. AP and
lateral fluoroscopy confirmed good alignment of implants.
A separate 8-inch ConstaVac drain was brought out through a
separate stab incision on the patient's left side. The
wound was irrigated with normal saline with Bacitracin
added copiously. A decortication was carried out of the
left residual S1 lamina, left residual L5 lamina, and the
residual pars and articularis on the left side and bone
graft packed in this area to affect a posterior fusion at
L5-S1 on that side primarily in the area just deep to the
rod.
The wounds were then closed in layers over this eighth-inch
ConstaVac drain using interrupted #2-0 Vicryl suture for
the fascial layer, #1 Vicryl suture for the deep fascial
layer, interrupted #2-0 Vicryl suture for the subcutaneous
layer, and staples for the skin.
A dressing was applied, the ConstaVac placed to selfsuction, and the patient transported to the postanesthesia
care unit in stable condition.