EXAMPLE
Emeka Nchekwube, M.D.
OPERATIVE REPORT
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ANESTHESIOLOGIST: Steven Wai, M.D.
ANESTHESIA: General.
PREOPERATIVE DIAGNOSIS:
1.
Lumbar disk herniation at L4-L5 with free fragment disk
(recurrent).
2.
Lumbar disk herniation, L2-L3.
OPERATION:
1.
L3-L4 bilateral extended laminectomy, epidural dissection,
and removal of a large free fragment disk.
2.
Left L2-L3 laminotomy, medial facetectomy, and
foraminotomy.
FINDINGS: The patient had a large, sequestered, free fragment
disk pushing against the thecal sac at L4-L5. At L2-L3 there was
a bulging disk with lateral recess and foraminal narrowing. She
also had facet hypertrophy and a thick yellow ligament.
INDICATIONS: The patient had a recent lumbar laminectomy at L4-L5
with removal of a free fragment disk with excellent result. She
returned home and after a few weeks, she reportedly bent over to
pick up an object and developed acute low back pain and left
sciatica, which became progressively disabling. Followup MRI
studies showed a recurrent disk at L4-L5 with a large sequestered
free fragment.
DETAILS OF PROCEDURE: 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 an incision
designed to excise the patient’s old lumbar laminectomy scar. A
fresh wound was thus created. Dissection then continued sharply
to the underlying subcutaneous tissue. The paraspinous muscles
were mobilized bilaterally in a subperiosteal fashion to expose
the posterior elements of L2, L3, L4, and L5.
Next, The laminectomy defect at L4-L5 was re-explored and the
bony landmarks defined. The laminectomy was then extended to
create a generous exposure, especially on the left side. The
dura was then mobilized along with the adjacent nerve root over a
large sequestered free fragment disk, which came out in one large
piece. The disk space was explored and noted to be empty. The
nerve root foramen was also explored on both sides and noted to
be free.
Attention was then directed to the L2-L3 disk level. Using an
Anspach high-speed precision drill, the L2 and L3 lamina was
drilled out partially including the medial half of the facet
joint to expose a thick yellow ligament, which was mobilized with
sharp dissection using sharp curettage. It was then excised to
expose the dura, which was mobilized medially along with its
adjacent nerve root. The L2-L3 disk space was explored and noted
to contain a moderate disk bulge, which was firm with an intact
annulus.
The nerve root foramen was then generously explored and
decompressed using a special angled Kerrison rongeur at L3 and
L4. Bony bleeders were secured with bone wax and epidural venous
bleeders with bipolar cautery. The wound was irrigated copiously
and after a final inspection, a #10 Jackson-Pratt drain was
placed in the depth of the wound and brought out through a
separate stab wound incision. Wound closure then commenced
anatomically in layers with #1 Vicryl suture for the deep fascial
layer, followed by 2-0 Vicryl suture for the superficial fascial
layer and subcuticular layer. The skin was brought together with
Steri-Strips. A sterile dressing was applied and the patient
left the operating room in a stable and satisfactory condition.
ESTIMATED BLOOD LOSS: 100 mL.