dlashua
Networker
Hi - I could use some help with this OP note - sorry it is so long
The operating microscope was brought in and the decompression and discectomy was performed under microscopic illumination and visualization. I started off with the Leksell rongeur and removed the interspinous ligament, the inferior 50% of the L3 spinous process, the superior 50% of the L4 spinous process and then denuded the apex of the lamina at both levels. I then brought in the Midas Rex high-speed air drill and thinned down the inferior 50% of the L3 lamina, the superior 50% of the L4 lamina and then took that dissection out into the inferior articular process of the L3 arch drilling that down in order to accommodate my medial facetectomy. At this point in the midline, I denuded the hypertrophied ligamentum flavum with the pituitary and Leksell rongeur. Ultimately was able to access the cleft between the two leaves that would lead me into the midline of the dorsal epidural space. I teased that open with an up going curet and then with a #2 and #3 Kerrisons got into that space and began to bite away the remainder of the ligamentum flavum, cut up underneath L3 down underneath L4 and then I began to widen that. There was very little central stenosis but very quickly as I went out laterally, the drop off was very steep indicative of medicalization of the facet joints and hypertrophy of the ligamentum flavum. I was ultimately just get out laterally out underneath the facet joint, taking away all the ligamentum flavum to the point where I could see the lateral recess and the edge of the thecal sac and L4 nerve root bilaterally. I went up underneath L3 far enough to get past the insertion of the ligamentum flavum down underneath L4 far enough to get past the insertion of the ligamentum flavum and then obviously out laterally completely taking the ligamentum flavum to free up the epidural space. I was able to palpate the medial superior aspect of the lower L4 pedicle bilaterally and I could easily slip a Woodson dissector out over the nerve roots. At this point, under higher illumination with a somewhat more lateral trajectory with the scope, I began to mobile thecal sac medially from the left. This was a centrally located disc herniation but it was certainly worse on the left, even though symptoms are worse on the right. My decision preoperatively was to access it from the left or bilaterally if necessary. I would take down any fibrovascular and fatty adhesions anchoring the sac to the disc in the epidural space. I was able to mobilize it with some difficulty, the reason being is that the dish herniation was very central, so it was very difficult to actually elevate the sac up over the central disc herniation. So what I ended up doing is I had my assistant retract it carefully and elevate it slightly. I then performed an oblique opening in the annulus with an 11 blade from the endplate of L3 to the endplate of L4 and then this allowed me to enter laterally the disc space itself and basically what I could appreciate, there was just a massive amount of fullness in this area. Everything was very hard. There was essentially no soft disc component to it. I was able to enter that and I began to tease out morcellized pieces of disc. This whole area of the annulus was very hypertrophied and essentially floating in the epidural space. What I ended up doing was taking a #2 Kerrison and cutting away the annulus in order to give me more working room into the disc space and then down caudal to the left L4 annulus where most of the disc material on the image preoperatively (MRI was located). Ultimately, I was able to make enough of an opening in the annulus. I could then take a ball-tip dissector and subsequently a right angle nerve hook and get down underneath the sac, underneath the exiting left L4 nerve root and then I began to actually tease out soft disc material. There was countless number of pieces that had obviously herniated from the base of the annulus and was in back and behind the L4 vertebral body over to the left. As I did this however, what I noticed is that there was just very hypertrophied annulus covering this whole thing that was very incompetent. Ultimately, I ended up just having to cut all that away. It appeared to me to be only causing mass effect. It was serving no function as it was disconnected from the endplate itself and basically what I think this represented was a blowout disc herniation that had lifted the annular fibers off to the back of the vertebral body and then had just settled into the ventral epidural space, creating mass effect. Ultimately we were able to retract the thecal sac more medially and I was able to get under it and cut away all the hypertrophied annulus as we would do in a fusion. I was able to get access to the central epidural space behind L4 tease out all of the free dis material and then at this point given that I was looking at a massive breech in the disc space literally looking down between L3 and L4; I exenterated the remainder of the disc. The disc was grossly incompetent with very little viable disc within it. I went in with a large pituitary and just removed any of the residual material that would have just come herniating out through this opening. I went in with both forward and reverse angled pituitary rongeurs and straight curettes ultimately was able to get out all the disc material that I felt would put the patient at risk for recurrence. At the end of the case, there may have still been some hard spondylotic calcified material in the very true center at the level of the L4 endplate as I could still feel some fullness with a nerve hook underneath the sac, but there was no way to access that and I felt that I had done my job in decompressing the thecal sac, both now ventrally and dorsally.
The operating microscope was brought in and the decompression and discectomy was performed under microscopic illumination and visualization. I started off with the Leksell rongeur and removed the interspinous ligament, the inferior 50% of the L3 spinous process, the superior 50% of the L4 spinous process and then denuded the apex of the lamina at both levels. I then brought in the Midas Rex high-speed air drill and thinned down the inferior 50% of the L3 lamina, the superior 50% of the L4 lamina and then took that dissection out into the inferior articular process of the L3 arch drilling that down in order to accommodate my medial facetectomy. At this point in the midline, I denuded the hypertrophied ligamentum flavum with the pituitary and Leksell rongeur. Ultimately was able to access the cleft between the two leaves that would lead me into the midline of the dorsal epidural space. I teased that open with an up going curet and then with a #2 and #3 Kerrisons got into that space and began to bite away the remainder of the ligamentum flavum, cut up underneath L3 down underneath L4 and then I began to widen that. There was very little central stenosis but very quickly as I went out laterally, the drop off was very steep indicative of medicalization of the facet joints and hypertrophy of the ligamentum flavum. I was ultimately just get out laterally out underneath the facet joint, taking away all the ligamentum flavum to the point where I could see the lateral recess and the edge of the thecal sac and L4 nerve root bilaterally. I went up underneath L3 far enough to get past the insertion of the ligamentum flavum down underneath L4 far enough to get past the insertion of the ligamentum flavum and then obviously out laterally completely taking the ligamentum flavum to free up the epidural space. I was able to palpate the medial superior aspect of the lower L4 pedicle bilaterally and I could easily slip a Woodson dissector out over the nerve roots. At this point, under higher illumination with a somewhat more lateral trajectory with the scope, I began to mobile thecal sac medially from the left. This was a centrally located disc herniation but it was certainly worse on the left, even though symptoms are worse on the right. My decision preoperatively was to access it from the left or bilaterally if necessary. I would take down any fibrovascular and fatty adhesions anchoring the sac to the disc in the epidural space. I was able to mobilize it with some difficulty, the reason being is that the dish herniation was very central, so it was very difficult to actually elevate the sac up over the central disc herniation. So what I ended up doing is I had my assistant retract it carefully and elevate it slightly. I then performed an oblique opening in the annulus with an 11 blade from the endplate of L3 to the endplate of L4 and then this allowed me to enter laterally the disc space itself and basically what I could appreciate, there was just a massive amount of fullness in this area. Everything was very hard. There was essentially no soft disc component to it. I was able to enter that and I began to tease out morcellized pieces of disc. This whole area of the annulus was very hypertrophied and essentially floating in the epidural space. What I ended up doing was taking a #2 Kerrison and cutting away the annulus in order to give me more working room into the disc space and then down caudal to the left L4 annulus where most of the disc material on the image preoperatively (MRI was located). Ultimately, I was able to make enough of an opening in the annulus. I could then take a ball-tip dissector and subsequently a right angle nerve hook and get down underneath the sac, underneath the exiting left L4 nerve root and then I began to actually tease out soft disc material. There was countless number of pieces that had obviously herniated from the base of the annulus and was in back and behind the L4 vertebral body over to the left. As I did this however, what I noticed is that there was just very hypertrophied annulus covering this whole thing that was very incompetent. Ultimately, I ended up just having to cut all that away. It appeared to me to be only causing mass effect. It was serving no function as it was disconnected from the endplate itself and basically what I think this represented was a blowout disc herniation that had lifted the annular fibers off to the back of the vertebral body and then had just settled into the ventral epidural space, creating mass effect. Ultimately we were able to retract the thecal sac more medially and I was able to get under it and cut away all the hypertrophied annulus as we would do in a fusion. I was able to get access to the central epidural space behind L4 tease out all of the free dis material and then at this point given that I was looking at a massive breech in the disc space literally looking down between L3 and L4; I exenterated the remainder of the disc. The disc was grossly incompetent with very little viable disc within it. I went in with a large pituitary and just removed any of the residual material that would have just come herniating out through this opening. I went in with both forward and reverse angled pituitary rongeurs and straight curettes ultimately was able to get out all the disc material that I felt would put the patient at risk for recurrence. At the end of the case, there may have still been some hard spondylotic calcified material in the very true center at the level of the L4 endplate as I could still feel some fullness with a nerve hook underneath the sac, but there was no way to access that and I felt that I had done my job in decompressing the thecal sac, both now ventrally and dorsally.