EXAMPLE
Emeka Nchekwube, M.D.
OPERATIVE REPORT
________________________________
ANESTHESIOLOGIST: Steven Wai, M.D.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSES:
1.
L3-L4, L4-L5 lumbar instability.
2.
L3-L4, L4-L5 lateral recess and foraminal stenosis.
POSTOPERATIVE DIAGNOSES:
1.
L3-L4, L4-L5 lumbar instability.
2.
L3-L4, L4-L5 lateral recess and foraminal stenosis.
OPERATION:
1.
Bilateral L3, L4, and L5 laminotomy, foraminotomy, and
lateral recess decompression.
2.
Posterolateral fusion L3, L4, and L5 using allograft
cortical bone chips and hydroxyapatite artificial bone
granules with bone morphogenic protein impregnated collagen
sheaths.
FINDINGS: The patient had a combination of spondylosis, thick
lamina, congenital facet hypertrophy, and spondylotic disease
with thick yellow ligament causing the pathological process. The
patient also has instability at L3-L4 and L4-L5.
INDICATIONS: Following satisfactory general endotracheal
anesthesia, the patient was placed prone on a specially padded
Wilson frame. The lumbosacral region was prepped and draped in
the usual fashion. The operation commenced with a midline
incision placed from L3 to the sacrum and taken down sharply
through the underlying subcutaneous tissue. The perispinal
muscles were mobilized bilaterally in a subperiosteal fashion and
exposure extended laterally to reveal the lateral elements
including the facet, pedicles, and transverse processes at L3,
L4, and L5. The lateral elements were then cleared of soft
tissues and decorticated using an Anspach high-speed precision
drill in preparation for fusion. At this time, it was very
obvious that the patient was grossly unstable at L3-L4 and L4-L5.
Attention was directed to the lamina at L3, L4, and L5, which was
opened up with the Anspach high-speed precision drill exposing a
thick yellow ligament.
It was then decided to perform a medial facetectomy in order to
gain as much exposure as possible without traumatizing the dura
and the adjacent nerve root. The lateral recesses were
decompressed as the yellow ligament was mobilized and removed.
This was very thick. The nerve roots were then exposed and
followed into the respective foramina where a generous
foraminotomy was carried out to decompress the exiting nerve
roots. The foramina were also noted to be tight. The procedure
was carried out on both sides at L3, L4, and L5.
The disk spaces were expected and noted to contain firm, partly
mineralized soft tissues, but no overt herniation. A small dural
opening was noted on the right at L3-L4, which was punctate and
suggestive of previous lumbar puncture site. With mobilization
under direct vision, this opening resulted in a brisk
cerebrospinal fluid leak. This leak was then repaired with a 7-0
Prolene suture, followed by application of fibrin glue, which
resulted in a tight seal.
Final inspection this patient was carried out and bony bleeders
were secured with bone wax and epidural venous bleeders with
bipolar cautery. The wound was irrigated copiously. Following
this, bone morphogenic protein was applied to collagen sheaths
and allowed to reconstitute in the usual fashion. The fusion
material consisted of hydroxyapatite artificial bone granule
blocks and cortical allografts and homographs were applied
centrally to the collagen sheath and rolled into a "burrito".
These "burritos" were then secured into the posterolateral gutter
from L2 to L5 to complete the fusion, and next a #10 JacksonPratt drain was placed on each side and brought out through
separate stab wound incisions. The wound closure then commenced
in anatomic layers with #1 Vicryl suture used to reapproximate
the deep fascia and the spinous processes to create an anatomical
closure of the deep fascial layer. The superficial fascial layer
was closed in a running fashion with 2-0 Vicryl suture and the
subcuticular layer was closed in a running inverted fashion with
3-0 Vicryl suture. A sterile dressing was applied and patient
left the operating room in a stable and satisfactory condition.
ESTIMATED BLOOD LOSS: 100 mL.