Laminectomy with Bilateral Foraminotomies Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Lumbar radiculopathy.
2. Lumbar spondylosis.
POSTOPERATIVE DIAGNOSES:
1. Lumbar radiculopathy.
2. Lumbar spondylosis.
PROCEDURE PERFORMED: L4-5 and L5-S1 decompressive laminectomy with bilateral foraminotomies.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, intubated, and placed under general endotracheal anesthesia. She was turned prone on a Wilson frame, which was maintained in its lowest position.
The patient’s back was prepped and draped in a sterile fashion. The previous incision was identified and outlined and infiltrated with Marcaine with epinephrine. The incision was opened to the lumbar fascia. The self-retaining retractors were placed. Paraspinal muscles were taken down bilaterally in a subperiosteal fashion using the Harmonic scalpel. There was some more scar tissue on the right but the process of L4 and L5 resected. Interestingly, the patient was narrowed on the left as well and actually also had narrowed foramen.
Attention was first directed to the right. The L5 foramen was actually narrowed but also the S1 root was extremely compressed, mainly from scar formation and also from thecal sac compression. She did not appear to have a herniated disk but had a very large spur underneath, which actually went significantly even over to the left side and that side was resected as well and actually the S1 root was significantly compromised also. Therefore, foraminotomy was also performed on that side. The L4-5 disk was slightly bulging but not herniated.
At L5-S1, we did examine the disk area. Again, really no herniation per se was identified. There was some disk material that was identified. However, primarily the bulge appeared to be a very large central spur. Again, by doing a decompression and foraminotomies, there will be hopefully significant room for the roots to get through as well as thecal sac without further compromising. The scar tissue was identified as stated, primarily on the right. This was also resected.
At the completion of the procedure, thecal sac and nerve roots bilaterally were both decompressed. Hemostasis was achieved with bipolar electrocautery in a manner using Gelfoam soaked in thrombin.
The wound was irrigated and noted to be clear. The wound was then closed in layers, 0-Vicryl used to reapproximate the muscle and fascia layer, 2-0 Vicryl to reapproximate the subcutaneous layer in inverted, interrupted fashion, and 3-0 nylon to reapproximate the skin edges in an interrupted fashion.
