DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
L4-5 stenosis.
POSTOPERATIVE DIAGNOSIS:
L4-5 stenosis.
OPERATION PERFORMED:
1. Left L4-5 partial hemilaminectomy, medial facetectomy, and foraminotomy.
2. Microdissection.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: 25 mL.
SPECIMENS: None.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old male with left back and lower extremity pain. He has had gradual onset of left back and lower extremity pain over the past couple of years. Four months ago, he developed severe left back pain extending into his lateral calf and ankle. He took pain medications and steroids, which mildly helped. The pain has persisted. It is worse with walking or standing and better with sitting or lying down. He has been using a cane recently. He has no low back pain or right leg symptoms. Since he has a pacemaker, a lumbar CT scan was obtained. This demonstrated mild to severe spinal stenosis at L4-5. His condition and imaging studies were reviewed with him. Treatment options, both surgical and nonsurgical, were discussed. The surgical procedure and its anticipated results were described. Risks, complications, and benefits of surgical and nonsurgical treatment were explained in detail. All questions were answered. The patient understood and consented to proceed with surgery.
DESCRIPTION OF OPERATION: After general endotracheal anesthesia was induced, he was turned into the prone position onto a Wilson frame. The patient’s lumbar area was prepped and sterilely draped in the usual fashion. A midline incision was made over the L4 and L5 spinous processes. Dissection proceeded through a thick layer of subcutaneous fat. The dorsal fascia was incised, and the paraspinous muscles were reflected laterally on the left side to expose the L4 and a small amount of the L5 laminae. A lateral lumbar spine film confirmed our position. Aesculap microdiskectomy retractors were placed. The operating microscope was brought into position.
Left L4-L5 partial hemilaminectomy, medical facetectomy, and foraminotomy were performed. A high-speed air drill was used to ascend down the inferior aspect of the L4 lamina and medial aspect of the facet joint. Approximately one-half of the inferior aspect of the L4 lamina and a minimal amount of the superior aspect of the L5 lamina were removed.
The ligamentum flavum was markedly thickened, which significantly decompressed the thecal sac and the left L5 nerve root. The dura reexpanded nicely with the decompression. Underneath the L5 lamina, there was a flash of clear fluid, which we assumed was related to a dural tear; although, we could not see the exact location of the tear. We placed DuraGen over this area, and there was no more leakage.
There was a minimal firm disk bulge. No diskectomy was performed. Following decompression, a hockey-stick elevator was passed into the epidural space, across the L4-L5 disk, on the L5 nerve root, out the neural foramen without resistance.
The operative site was irrigated with antibiotic solution. There was no active bleeding or clear fluid visualized. The operating microscope and self-retaining retractors were removed. The subcutaneous tissues and paraspinous muscles were infiltrated with 0.5% Marcaine with 1:200,000 solution of epinephrine.
The dorsal fascia was closed using 2-0 Vicryl and the subcutaneous tissue closed using 3-0 Vicryl. The skin incision was sealed using Dermabond. Sponge and needle counts were correct. The patient was turned back into the supine position. He was extubated and brought to the recovery room in satisfactory condition.
