INDICATIONS: This is a woman with severe leg pain, difficulty walking, weakness of the left leg reflexion of the foot, straight leg raising exam was positive. Imaging study showed a very large, extruded disc herniation L4-5 compression of the thecal sac. The patient was scheduled for surgery. After discussing the risks, benefits and possible complications of procedure, wished to proceed.
PROCEDURE: The patient was brought to the operating room and placed in the supine position. After appropriate monitoring lines and Foley catheter was placed, she was given general anesthesia and turned to the prone position on the Wilson frame. The back was prepped and draped in usual fashion. Localizing fluoroscopic image was taken.
Once this was done, a midline skin incision was made. Dissection continued through soft tissues Bovie electrocautery. The fascia was opened in the midline and the paraspinal muscles were elevated of both sides of lamina eccentric to the left side which was symptomatic. Cerebellar retractors were placed. Using Leksell rongeurs, the laminectomy of bottom of L4, top of L5 was performed. The drill was used to thin out
the medial facet on the left side. Medial fasciectomy was performed on the left this allowed mobilization of the dura in the nerve roots, which was identified. There was a large disc herniation extending above the disc space and complete compressing the ventral epidural space, this was carefully dissected away with a #4 Penfield dissector away from the dural and portions which were stuck were carefully dissected using
Down-pointing curettes.
Once this was done, a #11 blade was used to open up the capsule and the annulus and a thorough discectomy was performed. Once this was done, hemostasis was obtained. The nerve root was decompressed well. Foraminotomy was done. The dental tool was used to inspect the foramen and the ventral epidural space both above and below the disc space. The right side was explored also to ensure there was no fragment compressing the dura slightly and then palpating with a Penfield 4. Hemostasis was obtained. The Depo-Medrol was placed over the dura. The wound was closed in layers using 0-Vicryl for the muscle and fascia, 2-0 Vicryl subcutaneous tissues and staples for the skin. Clean sterile dressing was applied to the wound.