Wondering if i can pick some brains ....all suggestions are welcome and greatly appreciated!!!!

PROCEDURE PERFORMED
1. Posterior spinal fusion, L3-L4, L4-L5, using interspinous fusion device from Spine Wave, size 12 and size 10, respectively.
2. Posterior lumbar interbody fusion, L3-L4 and L4-L5 using the StaXx expandable interbody cage, size 14 at L3-L4 and L4-L5,
respectively.
3. Left-sided hemilaminectomy, complete facetectomy on the left at L3-L4, L4-L5, with decompression, exploration of the
L3-L4, and L5 nerve roots.
4. Aspiration of the right iliac crest, 30 mL of bone marrow and application of 40 mL of beta tricalcium phosphate.

DESCRIPTION OF PROCEDURE
A midline incision was directly made from L3-L5 and the spinous process of L3, L4, L5, identified. A Jamshidi needle was then used to aspirate 30 mL blood from right iliac crest and combined with 40 mL of beta tricalcium phosphate.

We then proceeded to decompression. Starting at L4-L5, we performed a laminotomy at L4-L5 worked out into the facet joint around the pedicle of lumbar 5, decompressed it fully, identified the L5 nerve root and decompressed the foramen. I also worked up at L4 and decompressed the L4 nerve root proximally. I also did a complete facetectomy at L4-L5. I then worked in a more proximal direction using Kerrison rongeurs and decompressed the dura centrally and worked up to the L3-L4 segment. Here I identified the pedicle of lumbar 4 and then worked up and palpated the pedicle of lumbar 3, identified the lumbar 3 nerve root. We decompressed the foramen of lumbar 3 and of lumbar 4. Great care was taken to make sure we maintained the spinous process integrity at all times. Once we had adequate exposure and decompression of the L3, L4, L5 nerve roots on the patient's left side, and confirmed this radiographically,

we then proceeded with the interbody fusion.Starting at L4-L5 on the patient's left, the nerve root of L4-L5 were protected and a full and complete discectomy performed out over
the endplates. I then back filled the disc spaces with beta tricalcium phosphate and autologous bone marrow and use a StaXx expandable interbody cage. We extended cage up to size 14 and it had excellent fit. It was not able to be moved. We then deployed the
gun and removed the inserting device and the cage was stable, and was no where near the nerve root. The nerve root was fullydecompressed. Gelfoam was applied.
Then at L3-L4 in a similar fashion on the patient's left side, while protecting the L3 and L4 nerve roots, we did a full and complete discectomy at L3-L4, using the disc preparatory devices. We then back filled the disc space with beta tricalcium phosphate and
autologous bone marrow and then deployed the cage inside the disc space to size 14.

We then proceeded with the posterior spinal fusion. Once we had adequate distraction with the cage at L3-L4 and L4-L5, we then started at L4-L5 and prepaired the spinous process of L4-L5. Here we chose a size 12 LANX interspinous fusion device. This was filled
with beta tricalcium phosphate and autologous bone marrow and placed between the spinous process of L4-L5 and locked according to manufacturer's specifications. In a similar fashion at L3-L4, we prepared the space between the spinous processes, then chose a size 10 cage. Great care was taken to make sure the cages were not touching each other and they were compressed against the bone and locked according to manufacturer's specifications. The wound was then thoroughly irrigated. Final x-rays were taken. There is no evidence of CSF leak. A drain was applied. FloSeal and antibiotic soaked Gelfoam placed in the exposed dura. The remaining bone graft was placed on the patient's right side over decorticate the lamina at L3-L5. The wound was then closed in several layers using #2 Polysorb suture, 2-0 and 3-0 for the skin. A dry dressing applied. The patient was taken to the recovery room.