Here's the OP Note. Thanks for your help!!!!!
PREOPERATIVE DIAGNOSES:
1. T11-T12 epidural and left foraminal mass.
2. Castleman disease.
POSTOPERATIVE DIAGNOSES:
1. T11-T12 epidural and left foraminal mass.
2. Castleman disease.
PROCEDURES:
1. T11-T12 extrapedicular left-sided biopsy of epidural and
foraminal mass with partial resection of the T11 and T12 rib
heads, as well as partial resection of T12 pedicle.
2. Use of intraoperative microscope with extradural microsurgical
dissection.
3. Use of intraoperative C-arm x-ray.
4. Use of Stryker Luxor minimally invasive retractor.
PROCEDURE IN DETAIL:
The patient was taken to the operating room, underwent a general
anesthesia, endotracheal intubation. Subsequently was positioned
prone on a Wilson frame in the Jackson table. We proceeded to
obtain a localizing x-ray after having placed 2 needles; 1 at the
L3 level, and 1 at the T12 level in the midline. Lateral lumbar x-
rays were then obtained and proceeded to count up until the level,
which was identified as T11-T12. At that site we then marked a 2.5-
cm incision that was about 2 cm lateral to the midline. After
prepping and draping the skin in the usual sterile fashion, we
proceeded to infiltrate the skin with 1% lidocaine. We then
proceeded to place a Steinmann pin at the level in the center of our
marked incision, and we obtained another lateral x-ray and
identified again that we were at the T11-T12 level. Once this was
identified, we then proceeded with opening of the incision with a
#10 blade, which was carried down through the skin, and subcutaneous
tissue down to the fascia, which was also incised with a #10 blade.
We then proceeded with blunt dissection down to level of the laminae
and rib head at T11-T12. We then proceeded to place our Stryker
Luxor retractor tubes, and proceeded to dilate the soft tissues
around that area up until the retractor was docked on the laminae,
and the rib head at T11-T12. A 6 cm retractor was then put in place
and attached with the light source, and the retractor was attached
to the attachment to the table. We then proceeded to obtain another
lateral lumbar x-ray to verify that we were at the adequate level,
which was the case. We then proceeded to dissect the soft tissue
using the Bovie cautery, and the pituitary rongeur up until we were
able to identify the bone at the rib head and laminae at T11 and
T12. Of note is that we elected to proceed more laterally and to
proceed with an extrapedicular biopsy as this appeared to be a safer
access, and we would avoid causing any type of pressure on the
spinal cord. We proceeded to resect part of the rib head at T11 and
at T12. We identified the pedicle of T12. A thick inflammatory
mass that appeared to be adherent to the soft tissue structures was
identified at T11-12. We were unable to visualize any neurovascular
element and we proceeded to take a few bites of the mass using a
small pituitary rongeur. Some of these were sent for frozen
pathology, which did reveal an inflammatory or a low-grade
lymphoproliferative process. The pathologist was unable to tell on
the frozen section whether or not we were dealing with Castleman
disease or a low grade malignancy. As such, we then elected to
proceed and resect further biopsy specimens. In the process we did
notice the intercostal nerve at that level that was inadvertently
injured, and cut as it was scarred down and had significant amount
of inflammatory tissue around it, and was unable to be
differentiated from the surrounding structures. Once an other
specimen of a few millimeters was then resected in a piecemeal
fashion, we then proceeded to achieve adequate hemostasis using the
bipolar cautery as well as FloSeal, followed by profuse irrigation
with antibiotic impregnated saline solution. We did use the
intraoperative microscope during resection of the deeper specimen.
We also spared the laminae __________proceeding with laminectomy
again to avoid causing possible damage close to the spinal cord as
the mass appeared to be significantly vascular, and adherent to
neighboring soft tissues. Once adequate hemostasis obtained, we
then proceeded to remove our tubular retractor after profuse
irrigation with impregnated saline solution. We proceeded to
closure in the usual fashion using 0-Vicryl interrupted suture for
the fascia, 3-0 Vicryl interrupted suture for subcutaneous tissue,
and a 3-0 Monocryl subcuticular suture for the skin.
