Neurosurgery Operative Sample Report #1
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chiari I malformation.
POSTOPERATIVE DIAGNOSIS: Chiari I malformation.
OPERATIONS PERFORMED:
1. Suboccipital craniectomy.
2. C1 laminectomy and C2 laminectomy with placement of dural expansion graft.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. She was then placed in a Mayfield headrest and positioned in a prone fashion on gel rolls. All bony prominences were inspected and padded prior to sterile draping. The suboccipital and posterior cervical area were then prepped and draped in the usual sterile fashion.
Using a 15 blade knife, the skin was incised in the midline and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect paraspinal muscles laterally exposing the suboccipital bone in the C1 and C2 lamina. A Leksell rongeur was then used to remove the C1 and C2 lamina, and Midas Rex drill was used to create a suboccipital craniectomy. The underlying dura was then freed from the hypertrophic transverse bands. A 15 blade knife was used to incise the dura in the midline, and an elliptical dural expansion graft made from bovine pericardium was sutured in place. The 4-0 Nurolon sutures were used to secure the graft. A watertight closure was verified with the Valsalva maneuver. The expansion graft was then reinforced with 5 mL of sprayed on Tisseel.
The wound was copiously irrigated with antibiotic solution. The fascia was then reapproximated in a watertight fashion using interrupted 0 Vicryl sutures. Interrupted 3-0 Vicryl sutures were then used to reapproximate the subcuticular layer, and staples were placed in the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.
Neurosurgery Operative Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right-sided L4-5 synovial cyst.
2. L4-5 grade I spondylolisthesis.
3. Bilateral facet arthropathy at L4-5.
4. Lumbar spinal stenosis secondary to all the above.
POSTOPERATIVE DIAGNOSES:
1. Right-sided L4-5 synovial cyst.
2. L4-5 grade I spondylolisthesis.
3. Bilateral facet arthropathy at L4-5.
4. Lumbar spinal stenosis secondary to all the above.
OPERATIONS PERFORMED:
1. Right-sided L4-L5 hemilaminotomy, partial medial facetectomy, and excision of synovial cyst.
2. Microdissection using operating room microscope.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who was injured at the workplace. He was diagnosed with worsening of a L4-5 synovial cyst. He experienced severe radiculopathy secondary to this. Having failed conservative interventions, the patient elected to proceed ahead with surgical option of excision of the synovial cyst.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Wilson frame. All bony prominences were inspected and padded prior to sterile draping. The lumbosacral area was then prepped and draped in the usual sterile fashion.
Using a #15 blade knife, the skin was incised in the midline and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect the paraspinal muscles laterally exposing the L4-5 interspace on the right side. Self-retaining Taylor retractor was placed, and lateral fluoroscopic imaging was then used to confirm proper localization.
We then brought the microscope into the field and used this to assist with performing a microsurgical hemilaminotomy at L4 and L5 and a partial medial facetectomy. The Midas Rex drill was used to bur down a small portion of the L4 and L5 hemilamina and the medial portion of the facet. We soon uncovered a large synovial cyst, which had evidence of hemorrhage within it, which would have occurred during his workplace accident. This also would have accounted for the sudden onset of his symptoms. The synovial cyst was completely released from the underlying dura with a micro nerve hook and removed completely decompressing the exiting L5 and L4 nerve roots.
Excellent decompression was achieved. The wound was irrigated with antibiotic solution. A small amount of Duramorph paste was placed in the epidural space for analgesia and 0.5% Marcaine in the subcutaneous tissues. The fascia was then reapproximated with interrupted 0 Vicryl sutures and subcuticular layer with interrupted 3-0 Vicryl sutures. A Dermabond dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.
Neurosurgery Operative Sample Report #3
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Unstable L1 burst fracture.
POSTOPERATIVE DIAGNOSIS: Unstable L1 burst fracture.
OPERATIONS PERFORMED:
1. Posterior open reduction of L1 burst fracture.
2. Placement of Synthes Schanz-type pedicle screws and rods from T12 through L2 nonsegmentally.
3. Posterior thoracolumbar arthrodesis from T12-L1 through L1-L2 using locally harvested morselized corticocancellous autograft bone and bone morphogenic protein-soaked sponges.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Jackson table. All bony prominences were inspected and padded prior to sterile draping.
Using a 15 blade knife, the skin was incised in the midline and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect paraspinal muscles laterally exposing the posterior elements from T12 through L2. Lateral fluoroscopic imaging was then used to place Synthes Schanz-type pedicle screws into the pedicles of T12 and L2 bilaterally. Excellent fixation was achieved.
The rod was then connected to the implanted pedicle screws and a two-stage reduction maneuver was performed. The fracture was distracted and then lordosed. This resulted in excellent restoration of vertebral body height, restoration of lordosis, and apparent reduction of the retropulsed fragment. The wound was then copiously irrigated with antibiotic solution. Two crosslinks were applied. The facets at T12-L1 and L1-L2 were then heavily decorticated exposing cancellous bone for fusion. The four facets were then packed with bone morphogenic protein-soaked sponges and morselized corticocancellous autograft bone.
A subfascial Hemovac drain was placed, and the fascia was then reapproximated using interrupted 0 Vicryl sutures. Interrupted 2-0 Vicryl sutures were placed in the subcuticular layer and staples on the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.
Neurosurgery Operative Sample Report #4
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Meningeal carcinomatosis.
POSTOPERATIVE DIAGNOSIS: Meningeal carcinomatosis.
PROCEDURES PERFORMED:
1. Placement of right frontal Ommaya reservoir.
2. Administration of 12 mg of intrathecal methotrexate.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman with a history of cancer who now presents with diagnosis of meningeal carcinomatosis. It was requested by the Hematology-Oncology service that an Ommaya reservoir be placed. Understanding all the risks and benefits of surgery, the patient elected to proceed with placement of an Ommaya reservoir.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed under general anesthesia. She was then placed supine on the operating room table. The right frontal area was then prepped and draped in the usual sterile fashion.
A horseshoe-shaped incision was created over Kocher’s point on the right side. A Midas Rex drill was then used to create a single entry bur hole at Kocher’s point. A ventricular catheter was then placed perpendicular to the skull entry bur hole and CSF was obtained at a depth of 5 cm. Clear colorless CSF was obtained; 15 mL of fluid was collected and sent for standard laboratory studies. An Ommaya reservoir was then connected to the catheter. The catheter length was set at 6.5 cm. Excellent CSF flow was achieved. Methotrexate 12 mg was injected into the catheter, administering the first dose of methotrexate.
The wound was then copiously irrigated with antibiotic solution and closed in the usual fashion using interrupted 0 Vicryl sutures in the galea followed by staples in the skin. A sterile dressing consisting of antibiotic ointment was then placed over the incision. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.
