marci_ann
Networker
Can anybody help me with this? I am new to neurosurgery. I have come up with 63047-(50?) and 63048-(50?)x2
PROCEDURE: Decompressive partial laminectomies and foraminotomies bilaterally
at L3-4 and L4-L5 and also on the right side at L2-3.
ANESTHESIA: General.
INDICATIONS: This 86-year-old man has had progressively severe back pain
radiating down the legs, worse on the right, associated on MRI with severe canal
and lateral recess stenosis, worst at L3-4 bilaterally, also bad at L4-5
bilaterally, but also significant on the right at L2-3.
FINDINGS: Rather than do a full laminectomy, given the patient's age and risk
factors, I elected to do a subtotal laminectomy and completely decompress the
areas of stenosis, leaving some lamina behind. We found, as expected, severe
stenosis at L3-4, slightly less at L4-5 and severe on the right at L2-3. There
was a small dural tear at L4-5, which was too small to receive a suture and was
covered by a blood patch with thrombin-soaked Gelfoam on top.
DESCRIPTION OF PROCEDURE: After identification in the operating room, the
patient underwent a general anesthetic with endotracheal intubation and was
placed prone on the Wilson frame with padding to all pressure points including
the elbows and around the eyes. After a mini prep, 2 spinal needles were placed
and x-ray taken to localize our eventual incision which we centered around L4.
We made an 8 cm midline lumbar incision, used sharp dissection and bipolar
cautery to go through the skin and subcutaneous tissues, separate these from the
surface of the lumbar fascia, then used a Bovie to incise the fascia in the
midline. The fascia was extraordinarily thin. The Bovie and periosteal
elevators were then used to sweep soft tissues off the spinous processes and
lamina on both sides as far as the facet joints at L3, L4, in the upper part of
L5, and the lower part of L2.
The remainder of the procedure was done using magnification with loupes. Self-
retaining retractors were applied.
The Horsley spine cutter was used to remove the spinous processes of L3 and L4.
These were very large and bulbous, as was L2 spine, and we could not do a
decompression, even a subtotal one, without removing these from view. We also
used double-action rongeurs to thin out the copious bony overgrowth of the right
side of the L2 spinous process as well. Finally, we removed the superior part
of L5 spine.
We began at L4-5. We did a limited laminotomy at the inferior L4 and superior
L5 lamina, going through a very thickened ligamentum flavum, using the smallest
of the Kerrison punches, a #15 blade, and Penfield #4 dissector until we
achieved the epidural space. Kerrison punches were used to resect this
laterally, superiorly and inferiorly until a blunt nerve hook demonstrated no
compression anymore. In the course of doing this, there was a very small dural
tear which nevertheless did produce some CSF leak. This was thought to be too
small to hold the suture, but was covered with a blood patch and a thrombin-
soaked Gelfoam. We noted no further CSF leak throughout the case from this
site.
We then turned our attention to the L3-4 level. Here we did a similar
procedure, somewhat more extensive since this was the area of most severe
stenosis. We removed the inferior L3 and superior L4 laminae, gained access to
the epidural space by resecting a very thickened ligamentum flavum, and from
here resected even thicker ligamentum flavum and joint tissue along the gap
between the 2 laminae, and then out toward the left and right lateral recesses,
where the facet joints were tremendously hypertrophic. Here, there was no
violation or injury to the dura whatsoever, in spite of it being extraordinarily
thin. A complete decompression was achieved and at the end, a blunt nerve hook
could be passed laterally in either direction toward the foramina as well as
rostrally and caudally to demonstrate no further neural compression.
Finally, we removed the inferior right L2 lamina, went through tremendously
thickened ligamentum flavum and joint tissue, gained access to the epidural
space at the midline or just to the right side of midline, and then used this
dissection plane to remove an incredibly overgrown facet joint and ligament.
Here again, at the end, blunt nerve hook demonstrated to inspection and
palpation, no further compromise of neural tissue rostrally or caudally or
laterally toward the foramen. There was no indication of any stenosis on the
left side.
Having achieved our objective and preserving at least partially the L3 and L4
laminae, we were satisfied that we had met our objectives without undue strain
or stress on this elderly gentleman. We therefore began closure.
The wound was copiously irrigated with antibiotic solution using the Pulsavac.
We were careful to make sure that the blood patch and thrombin-soaked Gelfoam
remained over the dura at L4-5, which it did.
The wound was then closed with simple interrupted 0 Ethibond for lumbar fascia,
making an effort to catch the muscle in this closure since the fascia was so
thin, and link sutures slightly more close to each other than usual for the same
reason. Vancomycin powder was placed in the subcutaneous tissues which were
also closed for dead space with inverted interrupted 3-0 Monocryl. Finally,
staples were used to close skin.
Antibiotic solution was applied and a standard dressing placed on top of that.
There were no intraoperative complications of note other than for a minor dural
tear, and at the time of this dictation, the patient is yet to be awaken from
anesthetic.
PROCEDURE: Decompressive partial laminectomies and foraminotomies bilaterally
at L3-4 and L4-L5 and also on the right side at L2-3.
ANESTHESIA: General.
INDICATIONS: This 86-year-old man has had progressively severe back pain
radiating down the legs, worse on the right, associated on MRI with severe canal
and lateral recess stenosis, worst at L3-4 bilaterally, also bad at L4-5
bilaterally, but also significant on the right at L2-3.
FINDINGS: Rather than do a full laminectomy, given the patient's age and risk
factors, I elected to do a subtotal laminectomy and completely decompress the
areas of stenosis, leaving some lamina behind. We found, as expected, severe
stenosis at L3-4, slightly less at L4-5 and severe on the right at L2-3. There
was a small dural tear at L4-5, which was too small to receive a suture and was
covered by a blood patch with thrombin-soaked Gelfoam on top.
DESCRIPTION OF PROCEDURE: After identification in the operating room, the
patient underwent a general anesthetic with endotracheal intubation and was
placed prone on the Wilson frame with padding to all pressure points including
the elbows and around the eyes. After a mini prep, 2 spinal needles were placed
and x-ray taken to localize our eventual incision which we centered around L4.
We made an 8 cm midline lumbar incision, used sharp dissection and bipolar
cautery to go through the skin and subcutaneous tissues, separate these from the
surface of the lumbar fascia, then used a Bovie to incise the fascia in the
midline. The fascia was extraordinarily thin. The Bovie and periosteal
elevators were then used to sweep soft tissues off the spinous processes and
lamina on both sides as far as the facet joints at L3, L4, in the upper part of
L5, and the lower part of L2.
The remainder of the procedure was done using magnification with loupes. Self-
retaining retractors were applied.
The Horsley spine cutter was used to remove the spinous processes of L3 and L4.
These were very large and bulbous, as was L2 spine, and we could not do a
decompression, even a subtotal one, without removing these from view. We also
used double-action rongeurs to thin out the copious bony overgrowth of the right
side of the L2 spinous process as well. Finally, we removed the superior part
of L5 spine.
We began at L4-5. We did a limited laminotomy at the inferior L4 and superior
L5 lamina, going through a very thickened ligamentum flavum, using the smallest
of the Kerrison punches, a #15 blade, and Penfield #4 dissector until we
achieved the epidural space. Kerrison punches were used to resect this
laterally, superiorly and inferiorly until a blunt nerve hook demonstrated no
compression anymore. In the course of doing this, there was a very small dural
tear which nevertheless did produce some CSF leak. This was thought to be too
small to hold the suture, but was covered with a blood patch and a thrombin-
soaked Gelfoam. We noted no further CSF leak throughout the case from this
site.
We then turned our attention to the L3-4 level. Here we did a similar
procedure, somewhat more extensive since this was the area of most severe
stenosis. We removed the inferior L3 and superior L4 laminae, gained access to
the epidural space by resecting a very thickened ligamentum flavum, and from
here resected even thicker ligamentum flavum and joint tissue along the gap
between the 2 laminae, and then out toward the left and right lateral recesses,
where the facet joints were tremendously hypertrophic. Here, there was no
violation or injury to the dura whatsoever, in spite of it being extraordinarily
thin. A complete decompression was achieved and at the end, a blunt nerve hook
could be passed laterally in either direction toward the foramina as well as
rostrally and caudally to demonstrate no further neural compression.
Finally, we removed the inferior right L2 lamina, went through tremendously
thickened ligamentum flavum and joint tissue, gained access to the epidural
space at the midline or just to the right side of midline, and then used this
dissection plane to remove an incredibly overgrown facet joint and ligament.
Here again, at the end, blunt nerve hook demonstrated to inspection and
palpation, no further compromise of neural tissue rostrally or caudally or
laterally toward the foramen. There was no indication of any stenosis on the
left side.
Having achieved our objective and preserving at least partially the L3 and L4
laminae, we were satisfied that we had met our objectives without undue strain
or stress on this elderly gentleman. We therefore began closure.
The wound was copiously irrigated with antibiotic solution using the Pulsavac.
We were careful to make sure that the blood patch and thrombin-soaked Gelfoam
remained over the dura at L4-5, which it did.
The wound was then closed with simple interrupted 0 Ethibond for lumbar fascia,
making an effort to catch the muscle in this closure since the fascia was so
thin, and link sutures slightly more close to each other than usual for the same
reason. Vancomycin powder was placed in the subcutaneous tissues which were
also closed for dead space with inverted interrupted 3-0 Monocryl. Finally,
staples were used to close skin.
Antibiotic solution was applied and a standard dressing placed on top of that.
There were no intraoperative complications of note other than for a minor dural
tear, and at the time of this dictation, the patient is yet to be awaken from
anesthetic.