DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Status post left L5-S1 microdiskectomy with cerebrospinal fluid leak status post two preoperative procedures for failed cerebrospinal fluid leak repair.
2. Lumbosacral instability, L5-S1.
POSTOPERATIVE DIAGNOSES:
1. Status post left L5-S1 microdiskectomy with cerebrospinal fluid leak status post two preoperative procedures for failed cerebrospinal fluid leak repair.
2. Lumbosacral instability, L5-S1.
OPERATIONS PERFORMED: Segmental arthrodesis with bony autograft, bilateral L5-S1; pedicle instrumented fusion of bilateral L5-S1; repair of cerebrospinal fluid leak; left L5-S1 facetectomy for cerebrospinal fluid leak repair; microscope used for nerve root microdissection around cerebrospinal fluid leak; and decompressive laminectomy, bilateral L5.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 250 mL.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, induced, and intubated without difficulty. He was rolled prone on a Williams frame table, and the old incision was scrubbed with a Betadine scrub brush and washed with alcohol. He was then prepped and draped in sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a 10 blade, Bovie. Sharp dissection to superficial fascial layers led to CSF collection just beneath the skin and superficial fascia. This was taken down to the spinous processes of L4-L5 and sacral ala. The subperiosteal dissection of the spinous processes and laminae of L4 and L5 and the sacral ala ensued. Deep retractors were placed. At this point, dissection was carried out over the L4-5 and L5-S1 facets freeing up the transverse process of L5 and S1.
Next, a tedious dissection began in the old operative site. A significant amount of ligamentum flavum remained as well as materials added in an attempt to stop the cerebrospinal fluid leak. The microscope was brought in and this material and ligamentum flavum began to be teased off. A decompressive laminectomy of L5 was then performed. The tear extended to the left facet at L5-S1 and bony removal included a facetectomy at this level. The bony fragments were dissected sharply off the dura as was the ligamentum flavum. Finally, the extent of the dural opening was identified. It was possible to close this dura at this dural tear primarily with 6-0 Prolene. Once this was accomplished, multiple Valsalva’s were used to confirm a watertight closure.
Next, a pedicle screw placement began in standard fashion of the transverse process and inferior facet junction at L4-5 was identified. The pedicle of L5 was palpated medially, starting on the left, a Midas Rex was used with an M-35 drill bit to drill a starting hole. A pedicle sound was used under fluoroscopic guidance. Palpation of this hole was followed with the use of a 5.0 tap. Palpation again was followed with placement of a 6.0, 45 mm screw. A 7.0, 35 mm screw was placed at S1. Identical screws were placed in the right at L5 and S1. Residual facet on the right, at L5-S1, was roughed up with transverse processes and sacral ala at L5 and S1, and other sides were roughed up. A pulsed jet irrigator was then used to irrigate out the wound.
Next, laminectomized bone had been mixed with NovaBone and this was laid along the transverse process and sacral ala at L5-S1. Rods were cut and contoured. These were secured to the construct with top-loading caps. The caps were provisionally tightened, then finally tightened. A piece of DuraGen was placed over the dural repair and Tisseel was placed over this DuraGen. Closure then began. The lumbodorsal fascia was closed with interrupted 0 Vicryl sutures. Superficial fascial layers were closed with interrupted 2-0 Vicryl sutures. The skin was closed with 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.
