Sample Report: Back Fusion with BAK Cages and Rod Instrumentation

Preoperative Diagnosis: Degenerative disk disease, L4-5 and L5-S1.

Postoperative Diagnosis: Degenerative disk disease, L4-5 and L5-S1.

Operation: Posterior lumbar interbody fusion, L4-5, and L5-S1 using BAK threaded fusion cages and Danek pedicle screws with local autogenous bone graft under fluoroscopy.

Anesthesia: General.

Procedure: The patient was identified and taken to the operating room, where he was given general anesthesia. He was given antibiotics, and the Foley catheter was placed as well as sequential compression stockings applied. He was transferred onto the surgical table in the prone position on the spinal frame. The back was prepped and draped in the usual sterile fashion. The initial approach to the spine as well as the decompression at the L4-5 and L5-S1 levels was done by the co-surgeon and will be dictated separately.

The fusion was done using the posterior lumbar interbody technique. BAK instrumentation was used. The L4-5 level was addressed first. The alignment guide was placed over the L4-5 disk space and the disk incised with a knife. The initial drill was used to make a hole into the disk space and then spacers were put in sequentially up to a size #12. The x-ray image intensifier was brought into the operating room and draped in a sterile fashion and introduced over the patient to provide a cross-table lateral x-ray of the lumbar spine. An x-ray was taken at every step of the way to provide optimal positioning of all instruments and implants.

The C-ring retractor was placed over the spacer on the left side, and the locking tube sleeve was inserted into the body of L4 and L5. The hole was then drilled with the hand drill and tapped with the hand tap. Loose fragments were removed with the straight pituitary. The assistant held retraction and protection on the nerve roots and dura at all times. At no time were these structures injured.

The cage was then selected and packed with bone graft. There was an abundant quantity of high-quality cancellous bone from the laminectomy, so no bone graft was needed from the iliac crest. This bone graft was packed into the cage at the distal end and then the cage was inserted. The proximal end of the cage was then packed with bone as well. The same technique was then done on the right-hand side and the same technique was done at the L5-S1 level for a total of four cages.

Because this was a two-level cage procedure, the pedicle screw instrumentation was used to augment the stabilization. The pedicle screw was put into the L4 vertebral body by making a bur hole at the junction of the facet joint and transverse process on the left. The assistant held visual and palpable protection of the pedicle and then the curette was used to make an entry hole into the pedicle. This hole was then replaced with the screw. The same technique was done on the contralateral side and at the S1 level bilaterally. The screw from L4 to S1 was connected to the other S1 screw with a rod on both sides, and then the rods were locked into place with the locking nuts. The rods were then connected with a transverse connector piece. A rigid construct was obtained. Final x-rays were taken and the wound was then closed in anatomic layers using interrupted Vicryl suture for the deep layer and staples for the skin. Sterile dressing was applied and the patient was taken to the recovery room in stable condition.