DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Neurogenic claudication.
2. Spinal stenosis, L4-5.
POSTOPERATIVE DIAGNOSES:
1. Neurogenic claudication.
2. Spinal stenosis, L4-5.
OPERATION PERFORMED: Lumbar decompression with decompressive partial laminectomy and foraminotomy, L4-5.
SURGEON: John Doe, MD
ANESTHESIA: General.
BLOOD LOSS: Less than 25 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After informed consent, the patient was taken to the operating room, and general anesthesia was induced. He was then placed prone on a Wilson frame. The pressure points and extremities were padded in the routine fashion. He was given routine preoperative prophylactic antibiotics and a time-out identified the operative site. The spine was then prepped and draped in the standard sterile fashion.
We made an incision from the L4 to the L5 spinous process. The incision was carried through the skin with a knife. We then used Bovie cautery to dissect down to the fascia. The fascia was then divided, and the paraspinal musculature was elevated out of the L4-L5 lamina out of the L4-5 facet, which was preserved. We then confirmed position with C-arm fluoroscopy. We then took down the spinous ligament at L4-5 and took down the cephalad portion of the L5 spinous process in the caudal region of the L4 spinous process. We then continued to work on the ligamentum flavum. There was tremendous hypertrophy of the ligamentum flavum, took significant amount of time to actually enter the spinal canal. Once we entered the spinal canal, again we were able to work on this significantly redundant ligamentum flavum. We used the bur to extend our partial laminotomy on the caudal portion of L4. We also took out a small portion of cephalad portion of L5. We were able to then continue to clear out the ligamentum flavum and bone out to the lateral recess. The lateral recess at L4-5 was then addressed using Kerrison protecting the dural sac with Woodson elevator and cotton padding. We then were able to also clear out the L4-5 foramen again using protection with Woodson elevator and cotton padding. Similarly, we were able to make sure that the dural sac had enough room for the transiting L5 nerve root. Following this, we felt like he had an adequate decompression. We could easily pass a Murphy ball probe out through the neural foramen and also under the L4 and L5 lamina without difficulty. We then copiously irrigated the incision. We had the anesthesiologist perform a Valsalva. There was subsequently no evidence whatsoever of a dural leak.
We then closed the fascia using 0 Vicryl in figure-of-eight fashion. We again copiously irrigated, closing the subcutaneous tissue with 2-0 followed by 3-0 Vicryl in interrupted fashion and a 4-0 Monocryl running subcuticular for the skin. Marcaine 0.5% was injected for analgesia. The sponge and needle counts were correct x2. The patient tolerated this procedure well and was taken to recovery in stable condition.
