Wednesday, November 9, 2011

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OP Report Sample for Idiopathic Lenke 3 scoliosis

PREOPERATIVE DIAGNOSIS: Idiopathic Lenke 3 scoliosis.

POSTOPERATIVE DIAGNOSIS: Idiopathic Lenke 3 scoliosis.

OPERATION PERFORMED
• Posterior lumbar instrumentation T2-L4.
• Posterior lumbar fusion T2-L4.
• Posterior type 1 swab osteotomies from T2-T5 and from T11-L3 and posterior type 2 swab osteotomies from T6-T10 for the purpose of a posterior release.
• Allograft.
• Local bone graft.

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 1800 mL.

IV FLUIDS: 4000 mL of crystalloid, 4 units of packed RBC's, 4 units of FFP, and 260 mL of Cell Saver.

OPERATION:
The patient was intubated in supine position with full ASA monitoring. SCD's were applied. Foley's catheter was placed. Neuromonitoring leads were applied. Patient was placed prone on the Jackson operating table. Pressure points were well padded. The back was adequately scrubbed, painted, and draped in usual sterile fashion. An adequate time-out was performed. A skin incision of adequate length was made in the midline of the axial spine in the back. Subcutaneous tissue was incised in the midline along the length of the skin incision. The fascia was incised over the tips of the spinous processes. The paraspinal muscles then carefully dissected from T2-L4. Width of the exposure was carried to the tips of transverse processes bilaterally from T2-L4. Then, our focus was shifted towards the posterior release. The interspinous ligaments were excised from T2-L4. Then, a type 1 swab osteotomy was performed from T2 to L5 and from T11 to L4. Type 2 swab posterior osteotomies were performed from T6-T10. The osteotomies were performed bilaterally and were performed for the purpose of a posterior release. Then, our focus was shifted towards placement of the pedicular screws. A neurosurgical bur was used to create a starting hole in the left L4 pedicle. A gearshift was introduced into the left L4 pedicle with gentle advancing of rotatory motion. The ball-tip probe was placed in the left L4 pedicle and all the walls of the pedicle were confirmed to be intact. Then, a tap was introduced into the left L4 pedicle. The ball-tip probe was reintroduced into the left L4 pedicle and all the walls of the pedicle were confirmed to be intact. Then, a 6.5 mm x 40 mm pedicular screw was placed in left L4 pedicle (Medtronics Legacy 5.5 polyaxial titanium). Similar anatomic method was used to create pedicular tracts in the right L4, both L3, both L2, both L1, both T12, the left T11, both T10, both T9, both T8, both T7, both T6, left T5, right T4, both T3, and both T2 pedicles. A 6.5 mm x 40 mm pedicular screws were placed in the right L4, both L3, both L2, both L1, both T12 pedicles. A 5.5 mm x 35 mm pedicular screws were placed in the left T11, both T10, both T9, both T8, both T7 pedicles. The medial wall of the right-sided pedicle was violated at T6 and the pedicular tract was abandoned. The left-sided T6 pedicle was abandoned due to medial wall violation and therefore a 5.5 mm x 35 mm pedicular screw was placed only in the right T6 pedicles. A 5.5 mm x 30 mm pedicular screws were placed in the left T5, right T4, both T3, and the left T2 pedicle. The right-sided T2 pedicular tract was thought to have a medial wall violation and therefore the pedicular tract were was abandoned. A downgoing transverse process hook was placed on the right side at T2. Then our focus was shifted towards the placement of the rod. The left-sided rod was measured, cut, contoured, and placed in left-sided tulips. Caps were introduced into the tulips to anchor the rod. Rod rotation maneuver was performed so that the rod lay in the correct sagittal plane. Then, direct vertebral body rotation was performed at L1, L2, L3, L4 as well as at T7, T8, T9, and T10. Then, the right-sided rod was measured, cut, contoured, and placed in the right-sided screw heads. Caps were introduced into the screw heads to anchor the rod. Final tightening of the caps was performed after compression across the apex in the thoracic as well as lumbar spine. After compression of the apex on the convexity of the thoracic and lumbar spine as well as distraction on the concavity in the thoracic and lumbar spine. Then, the exposed posterior elements were thoroughly decorticated from T2-L4. The spinous processes from T3-L3 were excised in order to harvest bone graft. Then local bone graft along with allograft was layered over the decorticated posterior elements, including the transverse processes from T2-L4. Then crosslinks were applied. Final tightening of the crosslinks was performed. Hemostasis was achieved. A deep drain was retained. Wound was closed in layers. Skin was closed with 4-0 Monocryl. Patient withstood the procedure well. Neuromonitoring was present throughout the entire surgery and there was no adverse event on neuromonitoring throughout the entire surgery. Intraoperative fluoroscopy was used to confirm adequacy of the construct. There was no evidence of a dural or nerve root injury throughout the entire surgery. Dressings were applied.

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