Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Neurosurgery Medical Transcription Operative Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES: 
1. Cervical disk herniation, C5-6, C6-7.
2. Cervical instability, C5-6, C6-7. 

POSTOPERATIVE DIAGNOSES: 
1. Cervical disk herniation, C5-6, C6-7.
2. Cervical instability, C5-6, C6-7. 

OPERATIONS PERFORMED: 
1. Anterior cervical strut graft arthrodesis C5-6, C6-7.
2. Anterior cervical osteophytectomy, C5-6, C6-7.
3. Anterior cervical decompressive foraminotomies bilateral, C5-6 and bilateral C6-7.
4. Anterior cervical plating, C5 to C7.
5. Microscope used for nerve root microdissection.

SURGEON:  John Doe, MD 

ANESTHESIA: General. 

ESTIMATED BLOOD LOSS: 20 mL. 

DESCRIPTION OF OPERATION: The patient was brought to the operating room after receiving IV antibiotics in the holding area. He was induced and intubated without difficulty. A roll was placed under his shoulder blade and SSEP monitoring was brought online. The right side of his neck was scrubbed with Betadine scrub brush and washed with alcohol. The C-arm fluoroscopy was used to mark out a right parasagittal transverse incision. This 4-cm incision was prepped and draped in sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a #10 blade. Sharp dissection to the platysma down to the anterior border of the sternocleidomastoid. Sharp and blunt dissection medial to this structure led into the paravertebral space. A handheld Cloward was used to retract the midline structures. The spinal needle was then placed in the C5-6 disk spacing, and this was confirmed with C-arm fluoroscopy. At this point, Bovie cautery was used to dissect the anterior longitudinal ligament of the inferior aspect of C5, the body of C6, and the superior aspect of C7. Medial and lateral rainbow retractors were placed in the field, posteriorly drilled into the bodies of C5 and C7. Axial distraction was applied. At this point, the microscope was brought in. Under microscopic guidance, the disk spaces were entered with a series of pituitaries. This was easy at C6-7, but difficult due to osteophytic disease and disk collapse at C5-6. 

Concentrating first on C6-7, curettes were used to remove disk material down to the posterior osteophytic disease. A #2 Kerrison was then used to remove these bone spurs. Decompressive foraminotomies were performed bilaterally at C6-7. Next, a nerve hook was used to fish out large fragments of disk material from behind the posterior longitudinal ligament. Once 5 or 6 of these fragments were removed, the thecal sac obviously was slackened. Copious irrigation at this point was followed with sizing of the defect. An 8-mm titanium strut graft packed with Osteofil was selected and tapped into place under fluoroscopic guidance. Attention was redirected towards C5-6, where the endplates were drilled down to the posterior osteophytes. These were removed with #2 Kerrison. Decompressive foraminotomies were performed bilaterally with the same #2 Kerrison. Again an 8-mm titanium strut graft packed with Osteofil was sized. This was tapped into place at C5-6. Next, the posts were removed and posts holes were waxed. A 42-mm anterior cervical titanium plate was chosen. This was secured to the bodies of C5, C6, and C7 with 12-mm variable screws and locking screws were tightened. Further irrigation was followed with closure.

Bleeding sites were cauterized. The platysma was closed with interrupted #3-0 Vicryl sutures after FloSeal was in the dissection area. The skin was closed with #4-0 subcuticular stitch. Steri-Strips were applied and dressing was placed on the patient’s neck. He awoke in good neurological condition and was taken to recovery room.


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:  Lumbosacral instability, L4-5; spinal stenosis, L4-5.

POSTOPERATIVE DIAGNOSES:  Lumbosacral instability, L4-5; spinal stenosis, L4-5.

OPERATIONS PERFORMED:  Segmental arthrodesis with bony autograft, L4-5; pedicle instrumented fusion, bilateral L4-5; posterior lumbar interbody fusion with cage placement, L4-5; decompressive laminectomy, L4; and decompressive foraminotomies, bilateral L4-5.

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.  She was rolled on a Wilson frame table, and the lumbosacral region of her spine was scrubbed with a Betadine scrub brush and washed with alcohol.  She had received IV antibiotics in the operating room.  A C-arm fluoroscopy unit was used to aid marking of the midline lumbar incision.  This area was prepped and draped in sterile fashion.  It was infiltrated with 1% Xylocaine with epinephrine and opened with a #10 blade.  Bovie cautery through superficial fascial layers led down to the lumbodorsal fascia.  Subperiosteal dissection of the spinous processes and lamina of L3, L4, and L5 ensued.  The dissection was carried out over the L3-4 and L4-5 facet.  The transverse processes of L4 and L5 on either side were freed out.  Deep retractors were placed in the wound at this point.  The C-arm fluoroscopy unit was again used to confirm the correct operative location.  A Leksell was used to remove the spinous process of L4 and thinned the lamina of L4.  It was clear that there was a pars defect at this level.  Curettes were used along the underside of L4 and a decompressive laminectomy was performed.  Large fragments of the superior facet at this level were likewise able to be removed en bloc and #4 Kerrison was used to perform decompressive foraminotomies bilaterally at L4-5.  A dental tool was used to ensure that these were freed up.  Once decompression was complete, the thecal sac was retracted medially from the right-hand side exposing the left L4-5 disk area.  Epidural veins were cauterized and covered with micro scissors, and the 11 blade was used to incise the disk space.  This material was removed with series of pituitaries and curettes.  After sizing, a 7 mm boomerang graft was selected.  This was tapped into the disk space under fluoroscopic guidance.  Bone had been packed in the boomerang prior to placement with the interbody device countersunk.  Attention was directed towards pedicle screw placement in standard fashion.  The inferior facet junction and transverse process at L4 was identified.  A Midas Rex was used to drill through the cortex in this area.  A pedicle sound was used at L4 under fluoroscopy guidance and direct palpation medially of the pedicle.  Once this had been done to a depth 50 mm, a thin probe was used to palpate the area.  A 5.0 tap was used to widen the hole.  Palpation again was followed with placement of a 6.0, 50 mm screw.  The transverse processes of L4 and L5 have been roughed up prior to the screw placement.  In similar fashion at L5, a drill was used to begin the pedicle screw hole.  A tap was used under fluoroscopic guidance.  Palpation of the hole was followed with use of a 5.0 tap.  Palpation again was followed with placement of a 6.0, 50 mm screw.  Attention was directed towards the right-hand side where identical screws were placed at L4 and L5.  A pulse jet irrigator was used to irrigate out the entire wound at this point.  Rods were cut and contoured.  Top-loading caps were applied.  These were provisionally tightened and finally tightened.  Bone morphogenic protein sponges packed with Mastergraft and laminectomized bone were laid along the transverse processes of L4 and L5 on either side.  At this point, FloSeal was placed in the lateral gutters.  A drain was brought out through a separate stab incision.  Closure then began.  The lumbodorsal fascia was closed with interrupted 0 Vicryl sutures.  The superficial facial layers were closed with interrupted 2-0 Vicryl sutures.  The skin was closed with a 4-0 subcuticular stitch.  Steri-Strips were applied.  A dressing was placed on the patient's back.  She awoke in good neurologic condition and was taken to the recovery room.