Diagnosis
Pre-op Diagnosis
* Acute midline low back pain with left-sided sciatica [M54.42]
* Spinal stenosis of lumbar region without neurogenic claudication [M48.061]
* Lumbar radiculopathy [M54.16]
* Spondylolisthesis of lumbar region [M43.16]
* Lumbar spondylosis [M47.816]
* Scoliosis of lumbar region due to degenerative disease of spine in adult [M41.56] | Post-op Diagnosis
* Acute midline low back pain with left-sided sciatica [M54.42]
* Spinal stenosis of lumbar region without neurogenic claudication [M48.061]
* Lumbar radiculopathy [M54.16]
* Spondylolisthesis of lumbar region [M43.16]
* Lumbar spondylosis [M47.816]
* Scoliosis of lumbar region due to degenerative disease of spine in adult [M41.56] |
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Procedures:
1. Posterior Spinal Arthrodesis, L2-5.
2. Posterior Segmental Instrumentation, Medtronic Solera Screws and Rods, L2-5.
3. Transforaminal Lumbar Interbody Fusion, L2-3, L3-4, and L4-5.
4. Intervertebral Disk Cage Placement, Medtronic Catalyft PL 40 Titanium TLIF Cages, L2-3, L3-4, and L4-5.
5. L2-3, L3-4, and L4-5 Laminotomies, Facetectomies, and Foraminotomies.
6. Use of Bone Morphogenic Protein-2.
7. Use of Medtronic Grafton Demineralized Bone Matrix.
8. Use of Cortical Morselized Bone Allograft.
9. Use of Harvested and Decompressed Local Bone Autograft.
Indications: 82 y.o with the above listed diagnoses. She has severe low back and left leg radicular pain that completely interferes with her function. Her symptoms have failed to improve despite extensive conservative management. She is extremely miserable and cannot tolerate her symptoms anymore. After counseling her, the shared decision was made to take her to the operating room for the above listed procedures. She understands the potential risks and benefits of surgery and has agreed to proceed with surgery.
Procedure Details: The patient was seen in the preoperative holding area. She has no known allergy. She was given vancomycin and rocephin then taken to operating room where a time-out was held with the surgical team, the anesthesia team, and the nursing team. We all agreed this was the proper patient and the proper planned operation. She was then given satisfactory general endotracheal anesthesia. Throughout her time in the operating room, sequential compression stockings were used on her legs. Under sterile conditions, a Foley catheter was inserted. We used standard suction. We also used spinal cord monitoring including somatosensory evoked potential monitoring, as well as motor evoked potential monitoring, and EMG monitoring. We used a face holder for head positioning. The patient was then turned from the supine to the prone position on a Jackson prone OR table and all potential pressure points were appropriately padded. Her back was prepped with alcohol, then chlorhexidine, and draped in the usual sterile fashion. A second time-out was held with the surgical team, the anesthesia team, and the nursing team and we again agreed this was the proper patient and the proper planned operation.
We began our procedure by localizing under fluoroscopy to verify the appropriate levels, L2-5. An incision was made along this area. The skin, subcutaneous tissue and deep fascia were incised in line with the skin incision. Subperiosteal dissection was used to dissect the paraspinal musculature off the dorsal arch and this was carried out wide to expose the transverse processes bilaterally from L2-5. We then turned our attention to performing our decompression. Using a combination of Leksell ronguer, Kerrison rongeur, curved curette, and Stryker electric Pi drive drill with a 3mm match stick bur, we first performed left L2-3, L3-4, and L4-5 facetectomies in preparation for our intervertebral disk cage placement. Following this we completed bilateral L2-3, L3-4, and L4-5 laminotomies, facetectomies, and foraminotomies to completely decompress that segment of the spine. After we were satisfied with our decompression, a Valsalva up to 40 was performed and held for 10 seconds and no visible CSF leak was observed.
Next, we turned our attention to completing our posterior segmental instrumentation, placing Medtronic Solera screws, of appropriate size and length, bilaterally from L2-5. I first percutaneously placed a Medtronic marker into the right ilium entering at the right PSIS. Medtronic O-arm was then brought into the room to capture multiplanar images of the patient's lumbar spine anatomy, following which Medtronic navigation system was used to safely and successfully place bilateral Medtronic Solera pedicle screws from L2-5. Screws were placed using the usual technique where once we confirmed our location with the navigation system, we used the high speed bur to drill a starting point followed by which Medtronic gear shift probe was used to cannulate a screw track. At each step, a ball tip probe was used to probe the screw track to ensure that there was an anterior end point and that we had not breached any of our four surrounding walls. Screws of appropriate length and size were placed and all were electrically stimulated using neuromonitoring techniques to ensure no direct contact with any neural elements. All screws tested satisfactory except the right L3 screw, which tested below 10. We, therefore, removed the screw and rechecked our walls and again no breach was appreciated. We, therefore, replaced the screw and checked radiographically and it looked appropriately placed on fluoro.
After we were satisfied with our decompression and posterior instrumentation, we then turned our attention to placing our interbody cages at L2-3, L3-4, and L4-5. I performed left-sided L2-3, L3-4, and L4-5 TLIFs. I used dilators to carefully dilate the disk spaces. I then used endplate preparation devices such as curettes and scrapers to remove the intervertebral disk contents and cartilaginous endplate for interbody arthrodesis. I then delivered from a left-sided transforaminal approach expandable Medtronic Catalyft PL 40 Titanium TLIF Cages and expanded them at each level until they were torqued out due to resistance. I ensured that I did not violate the superior or inferior endplates at any level. I then backfilled the cages with Medtronic grafton DBM fibers through a funnel. I had also pre-packed the disk spaces with 1cc of locally harvested and decompressed bone autograft and a small portion of a BMP sponge to facilitate interbody arthrodesis. The cages were satisfactorily positioned on AP and lateral fluoroscopic imaging. Once we were satisfied with our cage positions, a Valsalva up to 40 was again performed and held for 10 seconds and no visible CSF leak was observed. Neuromonitoring staff tested motor and sensory function throughout the entire procedure and at no point was there any changes from baseline.
We then measured and placed bilateral rods of appropriate length from L2-5, secured them with locking screw caps, and final tightened the screw caps with Medtronic Solera anti-torque screwdriver to the appropriate degree. We then thoroughly irrigated our incision bed with 3L of vancomycin infused NS. There were again no neuromonitoring changes.
Next, we extensively decorticated the transverse processes from L2-5. Following this we laid down BMP-2 soaked collagen sponges, generously packed locally harvested bone autografted and morselized cortical bone allograft bilaterally over our decorticated areas. We were very satisfied after laying down our BMP-2 and bone graft bilaterally. Final AP and lateral x-rays were then taken and it showed good position of the interbody cages, screws and rods, good alignment of the spine, and it showed that the bone graft was in good position bilaterally. Final neuromonitoring testing showed no changes from baseline.
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