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Neurosurgery Medical Transcription Operative Transcribed Sample Report

PREOPERATIVE DIAGNOSIS:  Spondylosis and right disk herniation, L5-S1.

POSTOPERATIVE DIAGNOSIS:  Spondylosis and right disk herniation, L5-S1.

OPERATIONS PERFORMED:  Right hemilaminectomy, medial facetectomy, foraminotomy, and diskectomy at L5-S1, on the right.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room.  After general endotracheal anesthetic, the patient was rolled prone on gel rolls.  We positioned and secured the trunk and appendages.  The patient was given 1 gram of perioperative antibiotics prior to the incision.  After the patient was prepped and draped in the usual fashion, PA and lateral fluoroscopy was used to help plan a paramedian incision at L5-S1, on the right, over the lateral mass.  The planned incision was infiltrated with Marcaine and sharp incision was carried through the skin, subcutaneous, and deep fascia.

A K-wire was brought down towards the lateral mass through the muscles.  Sequential dilators were placed over it and then a 4 cm x 22 mm METRx retractor was placed and affixed to the table with an attachment arm.  We confirmed our position on lateral fluoroscopy and did a hemilaminectomy and medial facetectomy with a 5 mm diamond bur on the Midas Rex drill, completed foraminotomy and medial facetectomy with 2 and 3 mm Kerrison rongeurs, identified the common dural sac, identified the S1 nerve root which was compressed underneath the ledge of facet, and with an underlying combination of osteophyte and disk herniation, the nerve root was gently mobilized with a Penfield 4 dissector, retracted with #8 French suction retractor.

An annulotomy was made with an 11 blade under loupe magnification and fiberoptic illumination after placing 1 mL of Marcaine irrigated on the S1 nerve root prior to retracting it.  We entered the disk space, removed some adjacent disk material, completed an S1 foraminotomy and medial facetectomy.  As the L5 nerve root was able to be easily palpated along its course, going out of a rather narrow foramen at this level as well, we attempted to try and open this up by undercutting a little bit more of the superior facet of S1, but this would have required a full facetectomy to further decompress and we did not want to destabilize the spine at this level by doing so. 

Hemostasis was adequate.  There were no complications.  No CSF leak.  The wound was copiously irrigated with antibiotic irrigation, and then, after that was aspirated out, we again placed another 1 mL of Marcaine over the nerve roots, removed the retractor, infiltrating the muscle and the subcutaneous tissue with more Marcaine.  The deep fascia was reapproximated, after ensuring excellent hemostasis, with 2-0 Vicryl.  The subcutaneous was closed with 2-0 Vicryl and subcuticular suture was used with 4-0 Vicryl and Steri-Strips to close the skin.  Sterile dressing was applied.  The patient was rolled onto his back and allowed to awaken.  The patient was then taken to the recovery room in good condition.