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Cervical Decompression Medical Transcription Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  C6-7 disk herniation with radiculopathy, right.

POSTOPERATIVE DIAGNOSIS:  C6-7 disk herniation with radiculopathy, right.

OPERATION PERFORMED:  Anterior cervical decompression with partial vertebrectomy and fusion, C6-7, using right iliac bone graft and Eagle plating.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA

ANESTHESIA:  General.

DRAINS:  None.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  20 mL.

DESCRIPTION OF OPERATION:  Under general anesthesia, the patient was positioned supine. Following padding of all bony prominences and routine preparation and draping, Dr. Doe provided an anterior approach to the cervical spine at C6-7. Once the levels had been confirmed radiographically, the procedure was undertaken. The annulus fibrosus was incised from one joint of Luschka to the other and removed piecemeal with a small rongeur. The anterior osteophytes were now taken down using a small rongeur as well. Bone wax was applied. The disk material was partially evacuated using a pituitary rongeur to decompress the disk at this point.

Once this had been accomplished, the Caspar system was introduced. Drill holes were made in the midline at C6 and C7 and Caspar screws applied. A Caspar distractor was applied over the screws and the interspace distracted. Using pituitary rongeurs and curettes, the interspace was now totally clean. The dissection was carried back to the PLL. There was some degree of osteophytic overgrowth posteriorly. Once all disk material and cartilaginous endplates had been taken down, a Midas-Rex was used to create a partial vertebrectomy. This was done using an AM-8 attachment. Once this was done, it was relatively straightforward to remove the PLL. By so doing, it was impossible to get further osteophytes removed posteriorly and to remove the disk material from the preforaminal area in the right posterior aspect of the interspace.

Once the canal had been decompressed using small pituitary rongeurs and angled curettes, the sclerotic bony endplates were taken down using a Caspar bur. Punctate bleeding bone was obtained. At this point, a separate incision was made over the wing of the right ilium. The dissection was carried down onto the ilium and the ilium was cleared on the inner and outer tables. Using a 7 mm parallel oscillating saw, a bone graft was obtained. This graft was now fashioned into a trapezoidal shape and fit into the interspace with a very slight interference fit.

Once this had been done, the Caspar system was removed with wax being applied over the holes created by the Caspar screws. A 14 mm Eagle plate was now obtained. The plate was bent to provide cervical lordosis and attached to the anterior cervical spine by means of four screws, two in each vertebra. Once the plate and screw had been placed, permanent x-rays were obtained which showed very good position of the plate and screws as well as the graft. As a result, at this point, final tightening of the screws was undertaken.

The wound was irrigated with antibiotic saline and an inspection was made. There was no excess bleeding. Likewise, the bone graft donor site was irrigated and Avitene applied. Both wounds were then closed in layers. A dry sterile dressing was applied over the iliac bone graft donor site and Dermabond was used on the skin of the neck. At this point, the patient was placed in a soft collar and transferred to the recovery room in good condition.

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