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Neurosurgery Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSES:
1. Cervical degenerative disk disease at C5-C6 and C6-C7.
2. Left-sided disk herniations at C5-C6 and C6-C7 with accompanying cervical radiculopathy.

POSTOPERATIVE DIAGNOSES:
1. Cervical degenerative disk disease at C5-C6 and C6-C7.
2. Left-sided disk herniations at C5-C6 and C6-C7 with accompanying cervical radiculopathy.

OPERATIONS PERFORMED:
1.  Decompressive anterior cervical diskectomies at C5-C6 and C6-C7.
2.  Microdissection using operating room microscope.
3.  Anterior cervical arthrodesis at C5-C6 and C6-C7.
4.  Placement of HSR cages packed with bone morphogenic protein-soaked sponges into the C5-C6 and C6-C7 interspaces.
5.  Placement of Sofamor Danek cervical spine locking plate from C5 through C7.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room, placed under general anesthesia, and then placed supine on the operating room table. The neck was placed in gentle extension to optimize cervical lordosis. The anterior cervical area was then prepped and draped in the usual sterile fashion. Using a #15 blade knife, the skin was incised in a horizontal fashion over the target interspaces. Monopolar cautery was used to dissect the platysma and blunt dissection was used to develop the avascular plane between the sternocleidomastoid and the medial strap muscles exposing the vertebral space. The longus colli muscles were elevated adjacent to the target interspaces and a self-retaining TrimLine retractor was placed. Lateral fluoroscopic imaging confirmed proper localization at the target interspaces.

A 15 blade knife was used to incise each interspace and the disk was grossly removed with pituitary forceps. The endplates were prepared for arthrodesis by removing all cartilaginous endplate material. The microscope was brought into the field and used to assist with performing a microsurgical decompression of the dorsal structures at C5-C6 and C6-C7. The posterior longitudinal ligament was opened with a micro nerve hook at both levels. There was an obvious free disk fragment at both levels on the left side, in particular at C6-C7, where there was a quite large free disk fragment. The fragments were grasped with a 2 mm punch and removed. The posterior longitudinal ligament was opened and further fragments were found and removed.

A foraminotomy on the left side was performed at both levels to adequately visualize both exiting nerve roots and confirm decompression. The wound was then irrigated with antibiotic solution. The interspaces were sized and two HSR cages of appropriate size were packed with bone morphogenic protein-soaked sponges and carefully impacted into the target interspaces. A Sofamor Danek cervical spine locking plate was then placed from C5 through C7 with screws placed at each vertebral body level. The wound was then closed in the usual fashion using a running 3-0 Vicryl suture in the platysma and a running 4-0 Monocryl in the subcuticular layer followed by Dermabond dressing. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

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