DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Unstable L2 burst fracture.
POSTOPERATIVE DIAGNOSIS: Unstable L2 burst fracture.
OPERATION PERFORMED:
1. Posterior lumbar open reduction of L2 fracture.
2. Placement of Synthes Schanz type screws and rods from L1 through L3 nonsegmentally.
3. Posterolateral facet arthrodesis from L1 through L3 using locally harvested morcellized corticocancellous autograft bone and BMP.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old man who was involved in an accident. He was underneath a scaffolding. The scaffolding apparently broke loose falling on top of him. The patient complained of the immediate onset of back pain but denied any numbness or weakness in his lower extremities. He was brought to the emergency room for further workup. Imaging showed evidence of an L2 burst fracture with fracture of the posterior elements. The fracture was deemed to be unstable, and it was recommended that surgery be done to realign the fracture and to reduce his kyphotic deformity.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Jackson table. All bony prominences were inspected and padded prior to sterile draping.
Using a #15 blade knife, the skin was incised in the midline, and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect the paraspinal muscles laterally, exposing the posterior elements from L1 through L3. Using lateral fluoroscopic imaging, we then proceeded to place Synthes Schanz-type pedicle screws into the pedicles of L1 and L3 bilaterally. Rods were then connected to the implanted pedicle screws, and a two stage reduction maneuver was performed, restoring lordosis intervertebral body height. The L1-2 and L2-3 facet articulations were then decorticated with a Leksell rongeur. The bone harvested from the decortication was packed into the decorticated facet articulations, and two large BMP sponges were then distributed into the facet capsules bilaterally to establish a posterolateral arthrodesis.
The wound was copiously irrigated with antibiotic solution. Lateral fluoroscopic imaging in the AP and lateral projections verified excellent fracture reduction. A subfascial Hemovac drain was placed, and the wound was closed in usual fashion using 0 Vicryl sutures in the fascia, interrupted 2-0 Vicryl sutures in the subcutaneous layer, followed by staples in the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.
