DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Lumbar epidural abscess.
2. Lumbar stenosis, L3 through L5.
POSTOPERATIVE DIAGNOSES:
1. Lumbar epidural abscess.
2. Lumbar stenosis, L3 through L5.
OPERATION PERFORMED:
1. Decompressive laminectomy, L3, L4, L5.
2. Evacuation of lumbar epidural abscess.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, PA-C
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100 mL.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, induced and intubated without difficulty. He was rolled prone on a Wilson frame table, and the lumbosacral region of his spine was scrubbed with a Betadine scrub brush and washed with alcohol.
The lumbosacral incision was marked out with the aid of the C-arm fluoroscopy unit. This was prepped and draped in sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a 10 blade. Bovie cautery through the superficial layers led down to the spinous process of L2 through the sacral ala. A subperiosteal dissection of the spinous processes and laminae of L3, L4, and L5 ensued. Deep retractors were placed in the wound with retraction at the L5 area on the right. Purulent drainage was seen in the psoas muscle. This was irrigated out and cultures were sent. A Leksell was used to remove the spinous processes of L5, L4, and L3. The same Leksell was used to thin the laminae at these levels. A #4 Kerrison was used to complete a decompressive laminectomy of L5, then L4, then L3.
Decompressive foraminotomies were performed on the right, as this was the area found to have epidural material. As the foraminotomies began to be performed, purulent drainage from behind the nerve roots at L3-4, L4-5 and L5-S1 came forth. This was irrigated out again after cultures were taken. Further irrigation with a pulse-jet irrigator and bacitracin solution was performed. At this point, closure began. A drain was brought out through a separate stab incision. Hemostatic agents were not used due to the infection present. The lumbodorsal fascia was closed with interrupted 0 Vicryl suture. Superficial fascial layers were closed with interrupted 2-0 Vicryl sutures. The skin was closed with a 4-0 subcuticular stitch. Steri-Strips were applied and a dressing was placed on the patient’s back. The patient awoke in good neurologic condition and was taken to the recovery room.
