AgnieszkaLakritz
Networker
Pre-op diagnosis:
1. Chronic, calcified lumbar disc herniation;
2. Lumbar spinal stenosis with neurogenic claudication;
3. Lumbar radiculopathy.
Post-op diagnosis:
same
Procedure done:
1. Open L4 laminectomy, bilateral L5 laminotomy, posterior approach;
2. Right L4-5 posterior facet augmentation/arthrodesis, with local bone autograft, without instrumentation;
3. L4/5 posterior endplate osteotomy, for resection of endplate osteophytes;
4. Open right L4/5 posterolateral foraminotomy, with outside-in technique, under direct visualization.
Procedure:
INDICATIONS FOR PROCEDURE:
This is a pleasant 32-year-old Caucasian female with chronic, calcified braod-based L4/5 disc protrusion, and moderate to severe L4/5 central stenosis and right L4/5 foraminal stenosis. She has failed extensive conservative treatment. She is here for the above stated open surgery as outpatient.
Patient was seen again at the pre-operative area, we went into details again about the risks and benefits about the above stated surgeries, which are not limited to: tissue or organ injuries including blood vessels, spinal cord/nerves, dura, nerve, infection, anesthesia reactions, increased pain, continuous pain, muscle weakness, need of additional surgery, or even death. The patient understood and consented to proceed the surgery. Informed consent was obtained, surgical site was marked.
DETAILED OPERATION PROCEDURE:
Patient was taken to OR and was placed prone on radiolucent Jackson table, after induction of MAC anesthesia. All pressure points were well padded. After timeout-and perioperative antibiotics was given, patient's lumbar-sacral area was prepped and draped in usual sterile manner.
I used fluoroscopy to identify the correct level and plan the incisions. A paramedian incision was made approximately 2CM off midline to the right side, after fascia incision,
The posterior part of the surgery was carried out through a standard paramedian incision, and layer by layer dissection, open Wiltse approach under direct visualization through para-spinal muscle layers. In detail, incise fat and lumbar fascia to spinous process, detach paraspinal muscles (erector spinae) subperiosteally, dissect down spinous process and L4 lamina to L4/5 facet joint under direct visualization, to expose the L4/5 segment. Next, a self-retaining retractor was placed. Next, with high-speed drill, angled-up curettes, and 2-mm Kerrison, L4 laminectomy, bilateral L5 laminotomy was done. The inferior 2/3 of the L4 laminar, and the superior 1/3 of the L5 laminar were drilled and resected. The ligamentum flavum was carefully elevated and resected. The decompression was carried laterally to the lateral recess bilaterally, and I visualized the decompressed thecal sac, the L5 traversing nerve roots, as well as the L4/5 disc space. Careful dissection was carried out throughout the case not causing any dura tear. Next, the thecal sac and the right L5 traversing nerve root were carefully retracted medially with blunt nerve root retractor, L4/5 microdiscectomy was done with micro-instruments under direct visualization to remove the significant sized herniation fragments. L4/5 endplate osteotomy was done with high-speed drill and micro-osteotome, to resect the significant sized endplate osteophytes. Careful dissection was carried throughout the case without causing durotomy.
Next, to prevent iatrogenic instability and to prevent development of degenerative spondylolisthesis, I turned attention to L4-5 posterior facet augmentation/arthrodesis without instrumentation. The self-retaining retractor was angled slightly laterally and right L4/5 facet joint was dissected and exposed, right L4/5 facet decortication was done with high-speed drill, and local bone autograft bone dust was packed into the decorticated facet joint for facet augmentation/arthrodesis.
Next, with posterolateral approach, I turned our attention to the OPEN right L4/5 foraminotomy with outside-in technique. Dilation was done with dilators docked on the right L4 pars, next, I placed the slef-retaining retractor over the dilators, after exposure of the right L4 pars, after dissection of the right L4/5 inter-transverse ligament under direct visualization, I identified the right L4/5 foramen. With a 2-mm, curved, angled Kerrison, right L4/5 open posterolateral foraminotomy was done by undercutting the right L4 pars and by undercutting the right L5 superior facet. An angled, blunt-tipped nerve hook was used to make sure I have achieved adequate decompression, and I visualized the decompressed right L4 exiting nerve root.
At this point, hemostasis was obtained with bipolar, all wounds were irrigated with copious normal saline, and closed in layers, sterile dressing was applied. Patient tolerated the above surgery well, there was no complications. She was turned to supine position, and taken to the recovery area in stable condition
Findings:
significant L4/5 DDD, endplate osteophytes.
22612, 63056, 63030-50 63047, 20936
this is total new to me, I am used to different techniques from my previous job
1. Chronic, calcified lumbar disc herniation;
2. Lumbar spinal stenosis with neurogenic claudication;
3. Lumbar radiculopathy.
Post-op diagnosis:
same
Procedure done:
1. Open L4 laminectomy, bilateral L5 laminotomy, posterior approach;
2. Right L4-5 posterior facet augmentation/arthrodesis, with local bone autograft, without instrumentation;
3. L4/5 posterior endplate osteotomy, for resection of endplate osteophytes;
4. Open right L4/5 posterolateral foraminotomy, with outside-in technique, under direct visualization.
Procedure:
INDICATIONS FOR PROCEDURE:
This is a pleasant 32-year-old Caucasian female with chronic, calcified braod-based L4/5 disc protrusion, and moderate to severe L4/5 central stenosis and right L4/5 foraminal stenosis. She has failed extensive conservative treatment. She is here for the above stated open surgery as outpatient.
Patient was seen again at the pre-operative area, we went into details again about the risks and benefits about the above stated surgeries, which are not limited to: tissue or organ injuries including blood vessels, spinal cord/nerves, dura, nerve, infection, anesthesia reactions, increased pain, continuous pain, muscle weakness, need of additional surgery, or even death. The patient understood and consented to proceed the surgery. Informed consent was obtained, surgical site was marked.
DETAILED OPERATION PROCEDURE:
Patient was taken to OR and was placed prone on radiolucent Jackson table, after induction of MAC anesthesia. All pressure points were well padded. After timeout-and perioperative antibiotics was given, patient's lumbar-sacral area was prepped and draped in usual sterile manner.
I used fluoroscopy to identify the correct level and plan the incisions. A paramedian incision was made approximately 2CM off midline to the right side, after fascia incision,
The posterior part of the surgery was carried out through a standard paramedian incision, and layer by layer dissection, open Wiltse approach under direct visualization through para-spinal muscle layers. In detail, incise fat and lumbar fascia to spinous process, detach paraspinal muscles (erector spinae) subperiosteally, dissect down spinous process and L4 lamina to L4/5 facet joint under direct visualization, to expose the L4/5 segment. Next, a self-retaining retractor was placed. Next, with high-speed drill, angled-up curettes, and 2-mm Kerrison, L4 laminectomy, bilateral L5 laminotomy was done. The inferior 2/3 of the L4 laminar, and the superior 1/3 of the L5 laminar were drilled and resected. The ligamentum flavum was carefully elevated and resected. The decompression was carried laterally to the lateral recess bilaterally, and I visualized the decompressed thecal sac, the L5 traversing nerve roots, as well as the L4/5 disc space. Careful dissection was carried out throughout the case not causing any dura tear. Next, the thecal sac and the right L5 traversing nerve root were carefully retracted medially with blunt nerve root retractor, L4/5 microdiscectomy was done with micro-instruments under direct visualization to remove the significant sized herniation fragments. L4/5 endplate osteotomy was done with high-speed drill and micro-osteotome, to resect the significant sized endplate osteophytes. Careful dissection was carried throughout the case without causing durotomy.
Next, to prevent iatrogenic instability and to prevent development of degenerative spondylolisthesis, I turned attention to L4-5 posterior facet augmentation/arthrodesis without instrumentation. The self-retaining retractor was angled slightly laterally and right L4/5 facet joint was dissected and exposed, right L4/5 facet decortication was done with high-speed drill, and local bone autograft bone dust was packed into the decorticated facet joint for facet augmentation/arthrodesis.
Next, with posterolateral approach, I turned our attention to the OPEN right L4/5 foraminotomy with outside-in technique. Dilation was done with dilators docked on the right L4 pars, next, I placed the slef-retaining retractor over the dilators, after exposure of the right L4 pars, after dissection of the right L4/5 inter-transverse ligament under direct visualization, I identified the right L4/5 foramen. With a 2-mm, curved, angled Kerrison, right L4/5 open posterolateral foraminotomy was done by undercutting the right L4 pars and by undercutting the right L5 superior facet. An angled, blunt-tipped nerve hook was used to make sure I have achieved adequate decompression, and I visualized the decompressed right L4 exiting nerve root.
At this point, hemostasis was obtained with bipolar, all wounds were irrigated with copious normal saline, and closed in layers, sterile dressing was applied. Patient tolerated the above surgery well, there was no complications. She was turned to supine position, and taken to the recovery area in stable condition
Findings:
significant L4/5 DDD, endplate osteophytes.
22612, 63056, 63030-50 63047, 20936
this is total new to me, I am used to different techniques from my previous job