Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy - 4

Description: C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate. Left cervical radiculopathy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Left cervical radiculopathy.

POSTOPERATIVE DIAGNOSIS: Left cervical radiculopathy.

PROCEDURES PERFORMED:
1. C5-C6 anterior cervical discectomy.
2. Bone bank allograft.
3. Anterior cervical plate.

TUBES AND DRAINS LEFT IN PLACE: None.

COMPLICATIONS: None.

SPECIMEN SENT TO PATHOLOGY: None.

ANESTHESIA: General endotracheal.

INDICATIONS: This is a middle-aged man who presented to me with left arm pain. He had multiple levels of disease, but clinically, it was C6 radiculopathy. We tested him in the office and he had weakness referable to that nerve. The procedure was done at that level.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room at which time an intravenous line was placed. General endotracheal anesthesia was obtained. He was positioned supine in the operative area and the right neck was prepared.

An incision was made and carried down to the ventral spine on the right in the usual manner. An x-ray confirmed our location.

We were impressed by the degenerative change and the osteophyte overgrowth.

As we had excepted, the back of the disk space was largely closed off by osteophytes. We patiently drilled through them to the posterior ligament. We went through that until we saw the dura.

We carefully went to the patient's symptomatic, left side. The C6 foramen was narrowed by uncovertebral joint overgrowth. The foramen was open widely.

An allograft was placed. An anterior Steffee plate was placed. Closure was commenced.

The wound was closed in layers with Steri-Strips on the skin. A dressing was applied.

It should be noted that the above operation was done also with microscopic magnification and illumination.

Keywords: neurosurgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples