Sample Name: Lumbar Laminectomy & Discectomy
Description: Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.
POSTOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.
1. Injection for myelogram.
2. Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.
BLOOD LOSS: Approximately 25 cc.
POSITION: Prone on the Jackson table.
INTRAOPERATIVE FINDINGS: Extruded nucleus pulposus at the level of L5-S1.
HISTORY: This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient.
PROCEDURE DETAIL: He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03. After a general anesthetic was administered, a Foley catheter was inserted.
At this time, copious irrigation was used to irrigate the wound. We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur. At this time, a small piece of Gelfoam was then used to cover the exposed nerve root. We did not have any dural leaks during this case. #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin. Sterile dressings were then applied. The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition. At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.
Keywords: orthopedic, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram,