Ahn Lumbar DC and Fusion  

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. 


Profound spinal stenosis with severe neurologic compression, L4-L5 with 

foraminal narrowing, L5-S1 with moderate-to-severe stenosis, L3-L4. 


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 



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. 



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 


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