DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right L4-L5 and right L5-S1 stenosis.
POSTOPERATIVE DIAGNOSIS: Right L4-L5 and right L5-S1 stenosis.
PROCEDURE PERFORMED: Right L4-L5 and right L5-S1 laminoforaminotomies.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
FINDINGS: Stenosis.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 50 mL.
SPECIMENS: None.
INDICATIONS: In brief, the patient is a pleasant (XX)-year-old female who previously underwent percutaneous L2 to L4 posterior spinal instrumented fusion. The patient did well for approximately 1 to 2 years and developed progressive pain down her left lower extremity. The patient underwent left L4-L5 and L5-S1 laminoforaminotomy, which alleviated the symptoms. More recently, the patient returned to the clinic complaining of right lower extremity pain. CT myelogram was obtained and demonstrated right-sided stenosis. The option of conservative care was discussed the patient’s. The patient underwent injection. Despite this, her symptoms did not abate. The patient opted to proceed with right L4-L5 and right L5-S1 laminoforaminotomies. Risks and benefits of right L4-L5 and right L5-S1 laminoforaminotomies included, but were not limited to, bleeding, infection, dural tears, neurologic injury, worsening neurologic status and risks of anesthesia. The patient consented to proceed with the right L4-L5 and right L5-S1 laminoforaminotomies.
DESCRIPTION OF PROCEDURE: The patient was seen in the preoperative holding area and the surgical site was marked. After successful induction of general endotracheal anesthesia, the patient was placed in the prone position on the Andrews table. The patient’s orbits, peripheral nerves and bony prominences were padded and protected. The back was then prepped and draped in sterile fashion. The patient was administered 2 grams of Ancef prior to incision. A safe timeout was performed.
A radiographic marker was used to localize the skin incision. A right L4-S1 paraspinal exposure was performed. The skin was incised with a scalpel and dissection was carried out with electrocautery.
Another radiograph was obtained to confirm the L4-L5 laminar space prior to proceeding with the laminoforaminotomy. The microscope was draped the remainder of the procedure.
A combination of curettes and Kerrisons were used to remove the outer portion of the ligamentum flavum. A high-speed bur was used to take down the leading edge of L4. The ligamentum flavum was released underneath this. The flavum was then removed from its attachment to L5 lamina and superior articular facet.
Dissection was then carried to the medial wall of pedicle. At completion of the laminoforaminotomy and the partial medial facetectomy, the thecal sac and the traversing right L5 nerve root were free. This procedure was then repeated at the L5-S1 level until the thecal sac and traversing right S1 nerve root were freely mobilized. At the completion of the procedure, the thecal sac and the right L5 and right S1 nerve roots were freely mobile.
Attention was turned to closure. All bleeders were controlled using bipolar cautery. There was no active bleeding at the time of closure. The wound was copiously irrigated. Closure was done in layers. Hemovac was placed through a separate stab incision prior to closure of fascia. The fascia was closed with interrupted 0 Vicryl, subcutaneous tissue was closed with 2-0, and the skin was reapproximated with 3-0 Monocryl and Steri-Strips. Sterile dressing was applied. The patient was awoken from anesthesia and transferred to the PACU in stable condition. All counts were correct x2 at the end of the procedure.
