Consent forms were signed. Risks and benefits of
surgery were discussed both with her and her son who is present. Certainly
risks included, but are not limited to infection, especially with rheumatoid
disease, misplaced screws or screws that pullout, especially considering her
rheumatoid disease and potentially soft bone. Other risks certainly include
dural tears, which is quite common with CSF leakage, which would necessitate
repair with stitch and artificial dura. Other risks include incomplete relief
of the pain and weakness and bowel and bladder issues, not resolving despite a
technically successful operation.
PREOPERATIVE DIAGNOSIS(ES):
Profound spinal stenosis with severe neurologic compression, L4-L5 with
foraminal narrowing, L5-S1 with moderate-to-severe stenosis, L3-L4.
POSTOPERATIVE DIAGNOSIS(ES):
Profound spinal stenosis with severe neurologic compression, L4-L5 with
foraminal narrowing, L5-S1 with moderate-to-severe stenosis, L3-L4.
COMORBID DIAGNOSIS: Rheumatoid arthritis with occipital cervical fusion and
cervical cord compression that was previously decompressed at another
operation.
PROCEDURE:
Posterior lumbar decompression of L3, L4, L5, top of S1 with three-dimensional
frameless stereotactic navigation Stryker spine unit with pedicle screws, Xia,
going from L4 down to S1 with local autogenous posterolateral bone grafting with
foraminotomies of L5 nerve root, L4 nerve root, S1 nerve root.
CLINICAL HISTORY:
OPERATIVE NOTE:
The patient was cleared by Anesthesia preoperatively. She has rheumatoid
disease. She has had a previous occipital cervical fusion for profound spinal
cord compression that was successfully decompressed and fused. She was given a
general anesthetic, log rolled prone onto a radiolucent Jackson table with
preoperative antibiotics for wound prophylaxis.
A skin incision was made going from L4 down to S1, and we exposed the bottom of
L3. We placed metal markers at L5-S1, L4-5 and the top of L4. We confirmed our
levels.
Pedicle screws were inserted at L4 down to S1 with three-dimensional navigation.
We used a sound. We got a good floor, good medial, lateral, superior, inferior
wall with no breaches. We then tapped, repeated the sound and then inserted the
6.5 x 40-mm pedicle screws at L4 and L5, and 6.5 x 35 at S1. We checked with AP
and lateral fluoroscopy also to confirm our screws were in good position.
We then put two rods, did our final tightening with a torque-anti-torque and
blocking caps. Under a microscope, we did decompression starting from L3,
including L4, L5 and at the top of S1. Foraminotomies were performed along with
removal of the ligamentum flavum. On the right-hand side at the level of
approximately L4, there was an incidental durotomy due to ligamentum flavum
being adherent to the dural sac. We used a 4-0 Nurolon stitch to close the
small dural opening. A minimal amount of CSF was seen.
We then, at the end of the case, tested the repair with a Valsalva maneuver. It
was watertight, no leakage occurred. We then sealed it up further with Evicel
fibrin sealant. We washed the wound out thoroughly with normal saline, packed
in morselized bone graft into the gutters along the transverse processes and
lateral to the screw heads. We then inspected the wound for any signs of
bleeding. It was nice and dry, especially with the Evicel and Surgiflo mixed
with recombinant thrombin. We closed the fascia with a #1 Vicryl in a
figure-of-eight fashion that was interrupted watertight, 2-0 for the
subcutaneous layer, staples for the skin. Dressings were then applied.
The patient is activity as tolerated
COMPLICATIONS: Incidental durotomy.
ADDITIONAL PROCEDURE PERFORMED: Duraplasty with 4-0 Nurolon stitch and 5 cc
Evicel.
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