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Kyphoplasty Procedure Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Pathologic fracture, T12, L4.
2.  Senile osteoporosis, T12, L4.

POSTOPERATIVE DIAGNOSES:
1.  Pathologic fracture, T12, L4.
2.  Senile osteoporosis, T12, L4.

OPERATION PERFORMED:
Kyphoplasty, T12 and L4, using biplanar fluoroscopy.

SURGEON:  John Doe, MD

ANESTHESIA:
Local with sedation.

COMPLICATIONS:
None.

ESTIMATED BLOOD LOSS:
Scant.

INDICATIONS FOR OPERATION:  The patient is an (XX)-year-old gentleman who developed 2 osteoporotic compression fractures. These were confirmed on MRI. Initially, the MRI report was read as only a compression fracture at L4 and no other fractures. However, subsequently, it was interpreted as edema in the T12 vertebral body as well. Because of this, we talked to the patient about doing a T12 kyphoplasty as well and he agreed. Consent was obtained.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room. The department of anesthesia administered IV sedation, and the patient was carefully log rolled into prone position on a Jackson table. All bony prominences were well padded. Biplanar fluoroscopy was brought into the field and targeted at the L4 vertebral body. This was localized in the AP and lateral projections simultaneously.

Next, the back was sterilely prepped and draped. The soft tissues overlying the pedicles of L4 were infiltrated with a mixture of lidocaine and epinephrine. A stab incision was made over each pedicle. A Jamshidi needle was then introduced via transpedicular approach into the body of the L4. This was done under fluoroscopic guidance.

Next, an exchange over the guidewire was performed and the Osteo introducer was positioned in the L4 vertebral body using biplanar fluoroscopic guidance. A tract was now created for inflatable balloon tamps with a drill. The balloons were inserted. The cavity was created. There was some reduction of the fracture. Balloons were then removed and polymethyl methacrylate cement was infiltrated into the vertebral body. There was no significant extravasation of cement. All instrumentation was removed at this time.

The biplanar fluoroscopy was now brought over the T12 vertebral body and it was localized in the AP and lateral projections simultaneously. Once again, the soft tissues overlying the left pedicle of T12 was infiltrated using a mixture of lidocaine with epinephrine. A stab incision was made, and using an unipedicular approach, the Jamshidi needle was then introduced into the body of T12 using fluoroscopic guidance. An exchange over the guidewire was performed and the Osteo introducer was positioned in the T12 vertebral body. A tract was created to the right side of the vertebral body and centrally, as well as to the left of center. An inflatable balloon tamp was put in place at the T12 vertebral body. Balloons were inserted. A cavity was created. Once again, there was some reduction of the fracture. The balloon was then removed and polymethyl methacrylate cement was infiltrated into the body. There was good fill to the right side, sooner into the left. There was no significant extravasation of cement.

All instrumentation was removed. The final intraoperative x-rays were performed with fluoroscopy in AP and lateral projections. This again showed the cement to be in good position in both the T12 and L4 vertebral bodies. The dressing was applied over the back in the form of Steri-Strips, 4 x 4, and clear dressing. The patient was returned to the hospital gurney and subsequently transferred to the PACU in stable condition.