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Hemilaminotomy Diskectomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Lumbar epidural abscess.
2.  Lumbar diskitis, L4-5.
3.  Lumbar vertebral osteomyelitis, L5.
4.  Lumbar vertebral osteomyelitis, L4.

POSTOPERATIVE DIAGNOSES:
1.  Lumbar epidural abscess.
2.  Lumbar diskitis, L4-5.
3.  Lumbar vertebral osteomyelitis, L5.
4.  Lumbar vertebral osteomyelitis, L4.

OPERATION PERFORMED:
1.  Right L4 hemilaminotomy.
2.  Right L5 hemilaminotomy.
3.  Diskectomy, right L4-5.
4.  Decompression of spinal canal at L4-5 purulent sanguineous material and scant disk debris.

OPERATIVE FINDINGS:
1.  Sanguineous purulent material was in the canal with scant disk debris.
2.  Tethered nerve root and dura dorsally and laterally prior to decompression.
3.  Freely mobile nerve root and gently pulsatile dura and nerve root following decompression.
4.  No evidence of CSF leak or bleeding upon Valsalva maneuver.
5.  No gross necrotic material outside the canal, deep in the wound or superficial in the wound.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Less than 200 mL.

DRAINS:  Two drains sutured in, one deep to the fascia and one subcutaneously.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  After consent was obtained, the patient was administered IV access and transported to the operating room and administered general endotracheal anesthesia.  Under sterile condition, Foley catheter was applied.  Lower extremity compression garments were applied.  The patient was placed prone on the Wilson laminectomy frame and secured with leather straps.   All bony prominences were well padded.  The Wilson laminectomy frame rested on the Jackson table.  Wilson laminectomy frame was cranked into a flexed position.  The lumbar spine was sterilely prepped and draped in the normal fashion.  Then, 18 gauge needles were placed for localizing radiographs.  After satisfactory anesthesia was obtained, the procedure was commenced.

An approximately 4 cm longitudinal incision was made over the L4-5 interspace with the #10 blade scalpel.  Electrocautery was used to divide the deep subcutaneous tissues and lumbodorsal fascia.  Subperiosteal dissection was performed from the right of the midline at L4 and L5.  The ligamentum flavum was identified.  It was removed using multiple passes of Kerrison and pituitary rongeurs.  Lateral recess was taken down.  The disk space was identified.  There was fluid and scant debris emanating from the disk contained by the posterior longitudinal ligament that was decompressed.  Prior to this decompression, the nerve root was tethered just medial to lateral recess and dorsally.  Following the decompression, the nerve root was freely mobile to 1.5 cm to the center of the canal.  The dura itself was pulsatile and found to be normal in appearance.  A Penfield 4 was used to probe the posterior aspect of the L4 and L5 vertebral body.  Very scant debris was revealed, but a predominance of sanguinopurulent material.

Following this, attention was then directed toward the L4-5 interspace.  Multiple passes of micro and regular pituitaries were made to decompress the disk space.  The disk space was copiously irrigated with sterile saline solution, impregnated with bacitracin, as was the canal and the deep wound.  Following the decompression and irrigation, the nerve root was freely mobile.  Dura was pulsatile.  Dura and nerve root showed micro pulsations.  Valsalva was negative for any CSF leak or any epidural bleeding.  Whatever epidural bleeding there was, was addressed with bipolar cautery within the canal.  Bleeding outside the canal was addressed with unipolar cautery.  Wound was copiously irrigated with sterile saline solution.

Deep fascia was reapproximated over a single Hemovac drain, which was made to exit to wound to the right of midline.  The lumbodorsal fascia was reapproximated using 0 Vicryl as a simple running stitch.  Deep subcutaneous tissues were reapproximated using 2-0 Vicryl as inverted interrupted stitches.  Deep dermis was reapproximated using 2-0 Vicryl as inverted interrupted stitches.  The subcutaneous was closed over a single Hemovac drain, which was made to exit the wound to the left of midline.  Skin edges were reapproximated using 2-0 Vicryl as interrupted vertical mattress stitches.  A sterile nonadherent dressing was applied.  Light compression dressing was applied.  Hemovacs were sewn to the skin, and the Hemovacs were placed to suction and secured with tape.  The patient was transported to the hospital gurney and aroused from her anesthesia and was found to have all motor units firing and was transported to the recovery room in satisfactory condition, after having tolerated the procedure well.  At the end of case, sponge and needle counts were correct.  There were no obvious complications.