Sample Report Herniated Disk Repair
Preoperative Diagnosis: Herniated disk with left sciatica.
Postoperative Diagnosis: Herniated disk with left sciatica.
Procedure Performed: Left L4-5 laminotomy, medial facetectomy, and diskectomy with microscope.
Anesthesia: General endotracheal anesthesia.
Indication and Consent: The patient is a 46-year-old gentleman with severe left hip pain and left sciatica. He cannot walk very far and has to crawl. MRI shows a large disk herniation of the L4-5 level. We discussed surgical intervention, the risks involved, the pre- and postoperative course. I have answered all his questions, and in accordance with his wishes, the following has been performed.
Details of Procedure: The patient was taken to the operating room. After induction of general endotracheal anesthesia, the patient was placed in the prone position on the Wilson frame. The back was shaved, prepped and draped in the usual aseptic fashion. A midline incision was made over the spinous process of L4 and L5. Subperiosteal dissection of the lamina of L4 and L5 was carried out with a Cobb periosteal dissector, and the Aesculap retractor system was placed in the usual fashion. The microscope was brought into place and Black Max drill with a blue #24 tip, which was used to perform laminotomies at L4 and L5, very small on L5, while pressure of the medial facetectomy was also carried out. The 3- and 5-mm punches were used to deepen this and also to take out the ligamentum flavum.
The nerve root was identified and teased from the disk with a #4 Penfield dissector and gently retracted medially with the Love nerve root retractor. Epineural veins were cauterized with bipolar electrocautery and the anus was cut with a #1 blade, and the disk was removed with pituitary rongeurs, straight up and downbiting. A small-diameter curette and Woodson instrument were all used to tease out a significant amount of disk from the disk space. This freed up the nerve root and dura nicely and cleaned out the disk space very nicely as well.
Wounds were irrigated with antibiotic solution. Hemostasis was achieved with bipolar electrocautery and bone wax as necessary. The wound was then closed in multiple layers using interrupted 0 Vicryl in the investing fascia, the second layer on the deep layer of superficial fascia and then an interrupted subcuticular closure was accomplished with 3-0 Vicryl. Benzoin and Steri-Strips were applied to the skin edges, and a sterile dressing was placed over the same. Needle and sponge counts were correct. Estimated blood loss was approximately 50 cc. Replacement was that of crystalloid only. There were no complications.
Postoperative Diagnosis: Herniated disk with left sciatica.
Procedure Performed: Left L4-5 laminotomy, medial facetectomy, and diskectomy with microscope.
Anesthesia: General endotracheal anesthesia.
Indication and Consent: The patient is a 46-year-old gentleman with severe left hip pain and left sciatica. He cannot walk very far and has to crawl. MRI shows a large disk herniation of the L4-5 level. We discussed surgical intervention, the risks involved, the pre- and postoperative course. I have answered all his questions, and in accordance with his wishes, the following has been performed.
Details of Procedure: The patient was taken to the operating room. After induction of general endotracheal anesthesia, the patient was placed in the prone position on the Wilson frame. The back was shaved, prepped and draped in the usual aseptic fashion. A midline incision was made over the spinous process of L4 and L5. Subperiosteal dissection of the lamina of L4 and L5 was carried out with a Cobb periosteal dissector, and the Aesculap retractor system was placed in the usual fashion. The microscope was brought into place and Black Max drill with a blue #24 tip, which was used to perform laminotomies at L4 and L5, very small on L5, while pressure of the medial facetectomy was also carried out. The 3- and 5-mm punches were used to deepen this and also to take out the ligamentum flavum.
The nerve root was identified and teased from the disk with a #4 Penfield dissector and gently retracted medially with the Love nerve root retractor. Epineural veins were cauterized with bipolar electrocautery and the anus was cut with a #1 blade, and the disk was removed with pituitary rongeurs, straight up and downbiting. A small-diameter curette and Woodson instrument were all used to tease out a significant amount of disk from the disk space. This freed up the nerve root and dura nicely and cleaned out the disk space very nicely as well.
Wounds were irrigated with antibiotic solution. Hemostasis was achieved with bipolar electrocautery and bone wax as necessary. The wound was then closed in multiple layers using interrupted 0 Vicryl in the investing fascia, the second layer on the deep layer of superficial fascia and then an interrupted subcuticular closure was accomplished with 3-0 Vicryl. Benzoin and Steri-Strips were applied to the skin edges, and a sterile dressing was placed over the same. Needle and sponge counts were correct. Estimated blood loss was approximately 50 cc. Replacement was that of crystalloid only. There were no complications.
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