Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Closed Reduction of Vertebral Fracture Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  C5-6 facet fracture. 
2.  Left C6 radiculitis. 

POSTOPERATIVE DIAGNOSES:
1.  C5-6 facet fracture.
2.  Left C6 radiculitis.

OPERATIONS PERFORMED:
1.  Attempted closed reduction of vertebral fracture and subluxation with traction. 
2.  Subsequent open reduction and treatment of vertebral fracture and subluxation. 
3.  C5-6 anterior cervical diskectomy and fusion. 
4.  Anterior cervical instrumentation C5-6. 
5.  Left anterior iliac crest structural bone graft harvest. 
6.  Use of operating microscope. 
7.  Application and removal of cranial tongs. 

SURGEON:  Jane Doe, MD

ASSISTANT:  John Doe, MD

ANESTHESIA:  Local followed by general endotracheal.

ESTIMATED BLOOD LOSS:  Approximately 100 mL.

IMPLANTS:  DePuy Eagle plate with four screws. 

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and using 1% lidocaine and antibiotic ointment, Gardner-Wells tongs were placed in line with the external auditory meatus approximately a centimeter above the ear. The anesthesiologist provided some conscious sedation. The patient tolerated the placement of tongs very well.

Ten pounds of traction were then added and a lateral C-arm image obtained, which showed persistent subluxation. Manual traction was then applied and maneuvers attempted with rotation as well as flexion and extension in an attempt to reduce the fracture. However, persistent subluxation was noted, and the decision was made to proceed with open reduction.

The patient was then administered general anesthetic with use of in-line traction. SSEP and EMG monitoring leads were placed. A Foley catheter was in place. Preoperative antibiotics were administered. SCDs were applied. The patient's arms were tucked to the side. The cervical spine and the left anterior iliac crests were prepped and draped in the standard sterile fashion.

A transverse incision was made overlying the C5-6 interspace. The platysma was divided in line with the incision. The anterior fold between the strap muscles, trachea and esophagus medially and the sternocleidomastoid and carotid sheath laterally was developed bluntly. The prevertebral fascia was incised and the subluxed level identified, both clinically as well as with a lateral C-arm image by placing a spinal needle within the disk space. The longus coli was elevated off of the C5-6 interspace bilaterally and self-retaining retractors placed below the longus coli muscles bilaterally.

The operating microscope was then brought in for the decompression and preparation of the anterior space. The diskectomy was performed with a series of curettes and rongeurs. The PLL was torn off of the posterior aspect of the C5 body; however, it was in continuity and there was no tear within its substance. The fracture was reduced via application of Caspar distractor and applying posterior translational force to the C5 body. AP, lateral and oblique C-arm images were obtained and showed perhaps a millimeter of residual subluxation related to rotational instability. This reduced with posteriorly directed force and rotation to the left, and it was felt that it could be held with the plate applied in this position. The disk space was measured with a trial and an 8 mm graft fit well.

An incision was made over the iliac crest over two fingerbreadths away from the ASIS. The fascia overlying the iliac crest was incised and the inner and outer tables exposed a couple of centimeters deep. Two Cobb elevators were placed within the wound to protect the soft tissues and an 8 mm by approximately 12 mm graft was harvested with an oscillating saw and osteotome. This was then placed within the C5-6 interspace and a single level Eagle plate applied with four screws, each of which had excellent purchase while holding the spine in a reduced position. The repeat C-arm images showed satisfactory alignment and placement of the instrumentation and graft.

The wound was thoroughly irrigated with antibiotic irrigation. A Penrose drain was placed and the platysma closed with interrupted figure-of-eight 3-0 Vicryl stitches. The skin was then closed with 4-0 running Monocryl stitch. The iliac crest wound was closed with 0 Vicryl interrupted figure-of-eight stitches within the fascia followed by 2-0 Vicryl interrupted buried stitches in the skin and a 4-0 running Monocryl. Steri-Strips and sterile dressings were applied to both wounds. A new Philadelphia collar was applied, and the patient's tongs were removed. The patient was awakened without difficulty and was able to move bilateral upper and lower extremities to command. The patient was then taken to the recovery room in stable condition. There were no intraoperative complications.

Neurosurgical Operative Samples #1     Neurosurgery Operative Sample Reports #2