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Anterior Cervical Diskectomy-Cervical Interbody Fusion Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Cervical spondylosis with myopathy (721.1).
2.  Cervical disk displacement (722.0).
3.  Cervical spinal stenosis (723.0).
4.  Cervical disk degeneration (722.4).

POSTOPERATIVE DIAGNOSES:
1.  Cervical spondylosis with myopathy (721.1).
2.  Cervical disk displacement (722.0).
3.  Cervical spinal stenosis (723.0).
4.  Cervical disk degeneration (722.4).

OPERATIONS PERFORMED:
1.  C5-6 and C6-7 complete anterior cervical diskectomy.
2.  C5-6 and C6-7 anterior cervical interbody fusion.
3.  Anterior cervical spinal instrumentation, C5 to C7.
4.  Insertion of structural allograft bone graft to C5-6 intervertebral space.
5.  Insertion of structural allograft bone graft to C6-7 intervertebral space.
6.  Spinal monitoring.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  150 mL.

URINE OUTPUT:  700 mL.

INTRAVENOUS FLUIDS:  1500 mL.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room. While supine on the operating table, general anesthesia was initiated. All appropriate lines and monitors were placed under sterile conditions, including Foley catheter and an arterial line. An interscapular roll was placed and the patient's head was placed on a well-padded headrest with 10 pounds of head halter traction. Lateral C-arm was brought into position. It was deemed necessary to tape the patient's shoulders distally in order to perform intraoperative lateral fluoroscopy. Utilizing Langer lines and appropriate bony landmarks, skin markings were made for a left-sided anterior approach to the cervical spine. All bony prominences were well padded. The patient's neck was then prepped and draped in standard surgical fashion. Landmarks were identified, and utilizing the previously marked skin incision, the skin and subcutaneous tissues were injected with lidocaine containing epinephrine. The skin was then incised with a scalpel and dissection was carried down carefully through the platysma with Bovie electrocautery. Bovie electrocautery was utilized throughout the procedure to maintain hemostasis, except when within the spinal canal, at which point bipolar electrocautery was utilized. Copious antibiotic irrigation at body temperature was performed at regular intervals throughout the procedure. After the platysma was carefully divided with Bovie electrocautery, blunt dissection was easily performed down to the anterior cervical spine. Stylet from the spinal needle was placed in the disk space and intraoperative x-ray confirmed operative levels. A meticulous subperiosteal dissection was then performed, exposing the inferior half of C5, the C5-6 annulus, the anterior C6, the C6-C7 annulus, and the superior half of the C7, beginning in the midline and then the subperiosteal, dissecting to the sides on both sides. Beginning first at C5-6, blunt self-retaining retractors were applied. The annulus at C5-6 was incised with a scalpel and a meticulous diskectomy was performed with a combination of curettes and pituitary rongeur. The endplates were denuded of any cartilaginous or disk material in preparation for spinal fusion. After all the disk material and cartilaginous endplates were removed, the posterior osteophytes were thinned with a bur and posterior disk fragments were removed with a micropituitary. The posterior osteophytes were removed from the midline with a microcurette and laterally with a micro-Kerrison. There were several midline herniated disk fragments. After the decompression was complete at C5-6, the disk space was copiously irrigated with antibiotic irrigation at body temperature. The retractors were released and reapplied at C6-7 and a similar procedure was performed with a complete anterior cervical diskectomy at C6-7 through the posterior longitudinal ligament with removal of posterior osteophytes and decompression of the spinal cord and the neural elements. Several midline disk fragments were encountered at C6-7 as well. The posterior osteophytes were thinned with a bur and the spinal cord was decompressed with a microcurette in the midline and uncovertebral osteophytes were removed with the micro-Kerrison. The appropriate size trial was chosen and then the appropriate size structural allograft bone grafts were chosen and prepared and covered with demineralized bone matrix. While this was taking place, the endplates at C5-6 and C6-7 were rasped with the appropriate size rasp in order to continue the preparation for spinal fusion. A punctate bur hole was made in the endplate of each vertebral body in preparation for spinal fusion, to allow the structural allograft bone graft access to bleeding cancellous bone. Punctate bur hole was made at C5 inferiorly, C6 superiorly, C6 inferiorly, and C7 superiorly. The disk spaces were again copiously irrigated with antibiotic irrigation and the structural allograft bone grafts were carefully and gently impacted into position, first at C5-6 and then at C6-7. With the structural allograft bone grafts in good position by direct visualization and lateral fluoroscopy, all traction was removed. The appropriate size plate was then chosen, contoured to improve cervical lordosis, and rigidly affixed to the anterior cervical bodies of C5, C6 and C7. All 6 screws had good bite. Lateral fluoroscopy confirmed good position of the instrumentation at C5, C6, and C7 as well as the intervertebral biomechanical structural allografts at C5-6 and C6-7. The locking mechanism was engaged at each level. Final fluoroscopic image was taken in the lateral position. The wound was covered. C-arm brought into the AP plane. This also confirmed good position of the structural allograft bone grafts at C5-6 and C6-7 as well as the instrumentation at C5, C6, and C7. The C-arm was then brought out of the field. The wound was then covered. The wound was again copiously irrigated with antibiotic irrigation. Hemostasis confirmed. A drain was placed just anterior to the plate, exiting posterior superior laterally in line with the skin incision, and the wound was closed in layers. The platysma was reapproximated with 2-0 braided absorbable suture placed in interrupted fashion, incorporating the skin and subcutaneous tissue with every other suture, in order to increase wound repair strength. The skin was then reapproximated with 2-0 braided absorbable suture placed subcutaneously in interrupted fashion and the superficial skin edges were closed with running 4-0 monofilament absorbable suture placed subcuticularly. The skin edges were cleaned and dried. Mastisol and Steri-Strips were applied. A small sterile dressing was applied. The patient was then awakened from anesthesia, extubated and transported to the PACU in stable condition, having tolerated the procedure well. All counts were correct at the end of the case. AP and lateral fluoroscopy confirmed operative level as well as good position of the instrumentation and the structural allograft bone grafts. Spinal monitoring was performed throughout the procedure and demonstrated no significant changes from baseline.