New to neuro / please help!!

ksrkelly7

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Hi all...

I usually don't do much neuro/spine coding. Could I please get some help with this OP report? Really appreciate it!

Thanks,

Kelly


Preoperative Diagnosis
1. Proximal Junctional Kyphosis
2. T10 Anterior Compression Burst Fracture
3. Bilateral T9 Pedicle/Pars fractures
4. Post Status Harrington Rod T10 to L2 fusion for Traumatic L1 Anterior compression burst fracture 1990's
5. Chronic Mechanical Back Pain



Postoperative Diagnosis
1. Proximal Junctional Kyphosis
2. T10 Anterior Compression Burst Fracture
3. Bilateral T9 Pedicle/Pars fractures
4. Post Status Harrington Rod T10 to L2 fusion for Traumatic L1 Anterior compression burst fracture 1990's
5. Chronic Mechanical Back Pain


Operation
1. Removal of T10 to L2 Harrington rod
2. Exploration of prior T10 to L2 fusion for a traumatic L1 burst fracture
3. Complete T9/ T10 laminectomy
4. Complete Bilateral T9/10 Facetectomy
5. Bilateral Ponte Osteotomies T7/8, T8/9, T10/11, T10/12, T12/L1, L1/L2
6. T7,T8,T9,T11, T12,L1,L2 CONFIDENCE Vertebroplasty
7. Segmental fixation from T7 through to L2 with DePuy Expedium
8. Auto/allograft arthrodesis from T7 to L2 with DBX Putty/Chips/CONFORM Allograft and morselized autograft
9. Open reduction and internal fixation of unstable fracture at T9/T10

Findings
Soft dystrophic bone
thin throacic pedicles

Specimen(s)
None

Complications
left L2 incidental durotomy
primary repair with 6.0 prolene and duragen/duraseal

Technique
The patient was brought to the operating room in the supine position where anesthesia administered a general anesthetic and endotracheal tube intubation. Modern diagnostics and anesthesia then aligned the patient appropriately for anesthetic monitoring, resuscitation and neurophysiologic monitoring. After final timeout identifying the patient, the procedure, reviewing her allergy status, with all her preoperative imaging on displaying the intraoperative view her, and her prophylactic antibiotic status reviewed we positioned the patient onto a Jackson table in a prone position.

Neurophysiologic baselines were then captured and satisfied we proceeded to plan our incision. Her previous incision line was clearly seen we extended this incision line approximately 5-6 cm superiorly our target exposure area from T6 to L3. Using AP and lateral intraoperative fluoroscopy we confirmed our target area and then proceeded to prep and drape the area in usual fashion.

We instilled 15 cc of 0.5% Marcaine with epinephrine are planned incision line. Scored the skin with a 10 blade and completed subperiosteal dissection down to the prior fusion mass from T 10 to L3 and superiorly exposing the spinous processes of T6 through to the fusion mass at T10. The prior bilateral Harrington rods were easily identified. A marked kyphotic deformity was seen at T9-T10 consistent with her known proximal junctional kyphotic fractures. Satisfied with our exposure out laterally to the transverse process and ribs placed deep Gelpi retractors and used copious amounts of bacitracin irrigant and achieved dry hemostasis with bipolar cautery, monopolar cautery, and FloSeal.

We explored the prior fusion site around the Harrington rods demonstrating a good bony fusion from T 11 through to L3 with no recognizable anatomic landmarks for her pedicles. We spent time demarcating residual transverse process from fusion mass as well as uncovering the rib and transverse process junction. We also uncovered the Harrington rod it was clear that there was looseness at the anchor ends at L2-3 and T10 suggesting pseudoarthrosis/instability at the junctional segments.

Using a variety of tools from the Harrington rod set we were able to loosen the rod construct and sequentially removed the rods first from the left than the right hand side in toto. We next explored the kyphotic deformity at the T9-T10 area. A pseudo-arthritic fibrous fusion mass was seen with dystrophic facets and bilateral pars fractures seen at T9. Bone quality was also found to be poor, easily curetted with steady bony marrow bleeding. Using Gelfoam and FloSeal bony edges were controlled.

In order to correct the pronounced kyphotic deformity is decided as necessary to release the spine with multilevel pathology osteotomies and planned complete resection of the T9 10 facet bilaterally. Using a Midas AMA drill bit the facets from T7–T8-T9 and T10-T11–T12-L1-L2 were drilled out bilateraly exposing the superior facets also aiding in distinguishing recognizable landmark anatomy or later placing a pilot holes for planned pedicle screw segmental fixation. Once bilateral upon she osteotomies were completed we used these new landmarks to place pilot holes in sequence starting on the left than moving to the right by using a lanky pedicle probe, followed by ball-tip probe to ensure that circumferential bony walls were present, then tapping the pilot hole and checking on AP and lateral fluoroscopy. The case was challenging because of patient's underlying anatomy with long thin pedicles that measured less than 3 mm in AP diameter, and degenerative rotatory thoraco-lumbar scoliosis. As we were placing the pilot holes it was clear that the bone quality was poor and decision was made to augment anchorage of our pedicle screws with vertebroplasty cement.

Prior to placement of the pedicle screws vertebral plasty cement was applied in each hole first starting on the left than on the right and in sequence with placement of cement into each hole and then placement of pedicle screw. This was done to complete placement of pedicle screws from T7-T8-T9-T11-T12-L1 and L2. An index screw at T10 was not placed due to the significant collapse and compression performed anterior compression burst deformity at this level. The amount of cement applied to each screw hole was monitored on fluoroscopy. The Left T7 pedicle was difficult to capture and instead a lamina hook was used at this level.

An incidental durotomy was discovered while attempting to cannulate the left l2 pedicle. A hemilaminotomy and partial 1/3 facetectomy was completed to expose a small 2mm tear at the nerve root sleeve. Using microsurgical technique this durotomy was repaired primarily with a single figure 8 6.0 prolene suture. A small 1cm duragen patch was placed with duraseal fibrin sealent. The left L2 pedicle was then cannulated and a pedicle screw as then placed under direct visualization into the pedicle.

A temporary rod was then placed into the right pedicle screws from T7 to L2 and locked into place with locking caps. We then turned our attention to the left facet of T9 10 and using a Midas drill we completely removed the facet and lamina en bloc using a combination of kerrison rongeurs and currettes exposing the thecal sac and exiting T9 nerve root and traversing T10 root in the lateral recess. Satisfied with her right sided decompression we then placed a temporary rod into the left pedicle screws from T7 to L2 locked this into place with locking caps and removed the temporary rod from the right T7 to L2 pedicle screws. We then again used a Midas drill to drill off the right-sided facet of T9 10 and remove the facet and lamina en bloc again using a combination of Kerrison rongeurs and curettes exposing the thecal sac and exiting left T9 and traversing T10 roots. We irrigated the wound with copious amounts bacitracin impregnated saline and used bipolar cautery and FloSeal to control epidural bleeding.

We checked our decompression circumferentially and satisfied we turned our attention to completing open reduction and internal fixation of her unstable proximal junctional T9/10 Burst pars fracture. We fashioned to titanium rods placing gentle 15-20' thoracic kyphosis in anatomic alignment after measuring the length using a monopolar cautery wire and snap placed into the heads of the pedicle screws on the left. we placed the rod starting in T7–T8-T9 and secured this with locking caps, we then released the right sided temporary rod and using the power reducers reduce the rod into the distal T11-T12–L1-L2 using 3 reduction towers in incremental steps. The effect of the multilevel pontine osteotomies as well as a complete facetectomy at T9/10 enabled enough flexibility in the spine visually reduce the spine into the planned rod curvature with minimal force. The rod was then locked into place with locking caps. The right sided pedicle screws were also secured similar fashion by premeasuring E titanium rod placing 15-20_6 thoracic kyphosis again repeating placement locking of the rod in the proximal T7-T8 and T9 pedicle screws and then reducing in a stepwise fashion to the T11-T12–L1-L2. By doing so there was some realignment in her rotatory scoliosis and significant improvement in her kyphotic deformity centered at T9/T10. During the reduction maneuvers was some concern in regards to screw pullout and/or medial shift/ break out from the vertebral bodies due to her poor quality bone and thin pedicles. The wound was irrigated with copious amounts of bacitracin saline.

Using a ball burr, the lamina of T7-T8-T9 and T11-T12-L1-L2 was decorticated. A 10 cc allograft conformer bone sponge was then divided in half and placed over the T9 10 complete facetectomy/pars defect. morcellized auto graft harvested from the laminectomy/facetectomy was mixed in with 10 cc of DBX allograft putty and bone chips with 1 g of vancomycin powder and this morcellized auto/allograft mix was then divided in half and packed into the posterolateral laminar gutters from T7 through L2.

A cross link was then placed across T9/T10 segment and in this manner segmental fixation from T7 through to L2 was completed with auto/allograft arthrodesis for open reduction and internal fixation of unstable proximal junctional fracture post status Harrington rod fixation/'fusion for old traumatic fracture.

A Hemovac drain was placed and the wound was closed in layers with 0 vicryl to the muscular and fascial layers; 0 vicryl to the deep subcutaneous layer, 3.0 vicryl to superficial subcutaneous layer and 3.0 monocryl and dermabond to skin.

SSEP/EMG signals stable with no changes throughout the case.
MAPS easily maintained >80 with fluids


Surgical Sweep Complete (Yes/No/Not Applicable)
Completex2

Disposition
Stable

Follow up plan
To ICU for vitals/neurovitals
resuscitation
pain control
 
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