Sample Name: Anterior Cervical Discectomy & Fusion - 6
Description: Anterior cervical discectomy with decompression of spinal cord. Anterior cervical fusion. Anterior cervical instrumentation. Insertion of intervertebral device. Use of operating microscope.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Symptomatic disk herniation, C7-T1.
FINAL DIAGNOSIS: Symptomatic disk herniation, C7-T1.
1. Anterior cervical discectomy with decompression of spinal cord C7-T1.
2. Anterior cervical fusion, C7-T1.
3. Anterior cervical instrumentation, anterior C7-T1.
4. Insertion of intervertebral device, C7-T1.
5. Use of operating microscope.
ANESTHESIOLOGY: General endotracheal.
ESTIMATED BLOOD LOSS: A 30 mL.
PROCEDURE IN DETAIL: The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service. He was placed in the supine position on an OR table. His arms were carefully taped down. He was sterilely prepped and draped in the usual fashion.
A 4-cm incision was made obliquely over the left side of his neck. Subcutaneous tissue was dissected down to the level of the platysma. The platysma was incised using electrocautery. Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle. This allowed us to get right down on to the anterior cervical spine. Blunt dissection was done to sweep off the longus colli. We isolated the C7-T1 interspace. An x-ray was taken to verify; we were indeed at the C7-T1 interspace.
Shadow-Line retractor was placed as well as Caspar pins. This provided very, very good access to the C7-T1 disk.
At this point, the operating microscope was brought into the decompression.
A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur. At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr. The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur. Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur. At the end of the decompression, there was no further compression on the left C8 nerve root.
A Synthes cortical cancellous ____________ bone was placed in the interspace. Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1. An x-ray was taken. It showed good placement of the plate and screws.
A deep drain was placed. The platysma layer was closed in running fashion using #1 Vicryl. Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl. Skin was closed in a running fashion using 4-0 Monocryl. Steri-Strips and dressings were applied. All counts were correct. There were no complications.
Keywords: neurosurgery, disk herniation, cervical discectomy, decompression, spinal cord, anterior cervical fusion, anterior cervical discectomy, kerrison rongeur, anterior cervical, instrumentation, cervical, anterior, platysma, kerrison, fashion, interspace, rongeur, discectomy, herniation,