SERVICE: Neurosurgery.
PREOPERATIVE DIAGNOSIS: L4-L5 spondylosis with spondylolisthesis and stenosis.
POSTOPERATIVE DIAGNOSIS: Spondylolysis at L4 with L4-L5 spondylolisthesis and stenosis.
SURGERIES PERFORMED: L4-L5 laminectomies, medial facetectomies, radical facetectomy on the right, medial facetectomy on the left; both interbody and posterolateral fusion using 10 with structural allograft interbody bone; local autologous morcellized bone; morcellized allograft bone; posterior nonsegmental instrumentation using Medtronic Solera pedicle screws.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
PERIOPERATIVE ANTIBIOTICS: Kefzol.
OPERATIVE FINDINGS:
- Morbid obesity.
- Poor bone quality (osteoporosis).
- 10 mm interbody implants were placed at L4-L5. They were spinal graft freeze-dried lordotic bone implants 4, 6.5 x 15 mm screws were used for instrumentation.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where he was induced under general anesthesia and endotracheally intubated without complication. Venodyne boots and Foley catheter were placed. He was positioned on the operating table resting on the Jackson frame in the prone position. His extremities were padded and protected. The back was prepped and draped in the usual sterile fashion. A safety pause was appropriately performed.
A linear midline incision was made in skin. Bovie electrocautery and Cobb dissector were used to provide subperiosteal dissections exposing the L4 and L5 lamina, facet joints and transverse processes. Transverse processes were extremely short in this gentleman. The Leksell rongeur was used to remove portions of the lamina and the spinous processes and these were morcellized and used for local autologous bone. They were mixed with crushed cancellous allograft bone (20 mL), mixed with local blood and then prepared in the bone mill for an even incised distribution in consistency.
After the laminectomy was performed, a complete diskectomy was performed bilaterally. Straight and upbiting pituitary rongeurs, various curettes, ring curettes, downbiting curettes and rasps were used to empty the disk space and prepare the endplates for perfusion. Sizes were used starting at 6 then 8 then 10 mm sizes of the implant. The facet joint on the right side was completely loose due to the pars interarticularis defect and was removed.
The interbody space was filled with the morcellized bone graft already prepared. The implant was tamped and recessed on the right side. More bone graft was placed on the left side. A new second implant was placed on the left.
Pedicle screws were placed at L4 and L5 under fluoroscopic guidance. Locking caps were connected using rods and then locking nuts. They were tightened to their full torque. The same morcellized bone graft was placed over the transverse processes bilaterally.
The wound was irrigated with antibiotic solution. Hemostasis was obtained using Surgiflo and bipolar electrocautery. The wound was closed over 10-French drain using 0 Vicryl for fascia, 2-0 Vicryl for subcutaneous tissue and 4-0 Monocryl in a running subcuticular stitch for skin. Mastisol, Steri-Strips and dry sterile dressings were applied. The patient was extubated in the operating room and brought to the recovery room in stable condition. There were no complications to surgery and all sponge and needle counts were correct.
