This is a little long but I appreciate the help. Thanks again, Jennifer
Proc: Anterior diskectomy at L5-S1 with AxiaLif percutaneous retroperitoneal technique and placement of a titanium interbody screw with mixture of morcellized bone graft. Optimum bone graft expander as well as platelet-rich plasma for fusion at the L5-S1 interval, posterior lumbar facet screws at the L5-S1 levels bilaterally, and posterolateral fusionat the L5-S1 to the posterior lateral gutters bilaterally using a minimally invasive technique for the facet screws and posterolateral fusion bilaterally at L5-S1. Additionally, we performaned a posterior lumbar decompression laminectomy and formaninotomy at the L5-S1 level.
Description: The patient was then placed prone on a Jackson table where all of her bony prominences were padded. The op proc began with AP and lateral fluoroscopic views identifying the sacrum as well as the sacral promontory and the coccyx tip in the AP and lateral planes. We then made a longitudinal incision from the tip of the coccyx near the coccygeal notch and the sacrospinal ligament and entered our 2cm incision with blunt dissection. We then punctured through the fascia, then used a blunt trocar and probe and carefully guided it along the anterior part of the sacrum. We stayed midline and followed the blunt trocar with fluoro guidance in teh Ap, lateral, and oblique planes for teh entire dissection. At no time was there any perforation of the colon noted throughout the entire procedure. We then guided our blunt probe to the sacral promontory and chose our sacral entry point in the midline. We tapped a guidewire up to the sacrum across the disk to the L5-S1 interval. The dilator trocar was then placed and a 9mm working tunnel was established. We drilled out the bone through the sacrum and initiated a radial diskectomy, scraping the endplates both superiorly and inferiorly circumferentially and as much disk material as possible was removed. Next, the tissue extractors were then used to complete the diskectomy. After this was completed, the disk was packed with a combination of morcellized autograft bone as well as Optimum bone graft expander, as well as platelet-rich plasma. We then used a 7.5 drill and inserted it through the sknin into the L5 vertebral body. Measurement was taken to measure out a 45x9x12 axial rod. The trasaxial rod was then placed over the exchange cannula. The rod was inserted into the S1-2 level. The exchange cannula was then removed. The wound was copiously irrigated with irrigation solutionand then the subcutaneous tissue was closed with 4-0 Vicryl sutures.
Our attention was then directed towards the posterior lumbar spine, where we made a midline incision at the superior aspect of the L3 spinous process. While we continued our incision through the dorsal fascia on both sides of the L3 spinous process, we then inserted a guide pin, introducer, and stylet on the patients left side and then on the right side. We then guided the introducer to the inferior articular process of L5 and the superior portion of the L5 facet using both AP and lateral fluoroscopic views to locate the facet joints. We then removed the stylet from the guide pin and inserted it though the fascia into the guide pin assembly. We then used a slap hammer to lightly dock the cannulated guide pin into the inferior process of teh L5 vertebral body. We then removed the guide pin handle then inserted through the cannulated guide pin sheath and using the wire driver of teh long pin it was inserted into the L5-S1 interval so that it would securely engage the L5-S1 facet. We verified placement of the guide pin in the AP and lateral planes. The introducer was then removed leaving the cannulated guide pin and the long guide pin. We then advanced the sheath to the guide pin and removed the 6mm dilator. We then inserted a facet drill along the guide pin and through the sheath, we used a facet drill to drill a pilot hole across the facet joint. We placed two #25 facet screws along the guide pin on the patients right and on the left side at the L5-S1 facet. We verified position in the AP and lateral planes at all times. We then placed a combination of morcellized autograft bone, Optimum bone graft putty, as well as platelet-rich plasma along the posterior gutter at the L5-S1 interval. The wound was then closed with 3-0 Vicryl suture and final closure with Dermabond.
We then moved over the L5-S1 interval and confirmed location with the C-arm in the AP and lateral planes. We made a midline incision down to the fascia and then confirmed our L5-S1 level again. We then dissected down to the facet joints over the L5-S1 interval. We performed a complete laminectomy and foraminotomy at the L5-S1 level and ensured that our nerves were free and clear and there was no debris overlying the nerve roots. After satisfactorily completing our foraminotomy and laminectomy, we then copiously irrigated the wound with irrigation solution. We placed a drain from the skin to under the fascia and used #1 Vicryl suture and reinforced with Seri-Strips.
