Neurosurgical Medical Transcription Operative Sample Reports for MTs:
OPERATIONS PERFORMED: Operative treatment of L1 fracture, T12 to L2 posterior spinal fusion, T12 to L2 nonsegmental posterior spinal instrumentation, and right posterior iliac crest morcellized bone graft harvest.
DESCRIPTION OF OPERATION: The patient was taken to the operating room. After the induction of general anesthesia, the patient was carefully log-rolled into a prone position on a well-padded Jackson spinal frame. His legs were kept extended on a flat footboard. His arms were placed in no more than 90 degrees of abduction and slightly forward to his body. His axillae were free of pressure. SCDs had been applied. A Foley catheter was in place. Preoperative antibiotics were administered. Leads for SSEP monitoring had been placed prior to the prone position and baselines were obtained. These baseline readings remained stable after positioning and throughout the procedure. The patient's posterior thoracolumbar junction showed a slight kyphotic deformity, which improved only somewhat with prone positioning. The patient also had some soft tissue fullness over the area of his incision, consistent with his muscular injury as noted on the MRI scan. His posterior spine and pelvis were prepped and draped in a standard sterile fashion, first with a wet prep and then with ChloraPrep, and Ioban was applied. The posterior spine was exposed from the tip of the T11 spinous process to the L2 spinous process. As soon as the incision was made, paraspinal musculature was noted to have herniated out through a fascial defect and was lying immediately subcutaneous. Devitalized muscle was removed and a large fascial rent identified and tracked down to the interspinous region between the L1 and T12 spinous processes. The interspinous ligaments as well as ligamentum flavum were severely disrupted and a clot noted in the region of the proximal spinous process fracture at L1. The fracture fragments were removed as well as the remainder of the soft tissue ligaments in order to clear out the spinal canal for when the fracture was later reduced. No dural tear was encountered, although a remnant of ligamentum flavum remained over the dura and this layer was not removed. Exposure was carried out laterally to the tips of the transverse process bilaterally. Starting points for pedicle screws were marked bilaterally at T12 and L2. The pedicles were cannulated with a Lenke probe and appropriate interosseous passage confirmed with a ball-tipped probe and the length of the pedicles measured. Thus, 6.5 x 50 mm screws were placed bilaterally at L2 and 6.5 x 40 mm screw on the left at T12 and 6.5 x 45 mm screw on the right at T12. All screws had excellent purchase.
Attention was then directed to the right posterior iliac crest. An approximately 3 cm oblique incision was made over and lateral to the PSIS. Subcutaneous hemostasis was achieved with electrocautery. The fascia overlying the PSIS was incised and the outer table of the pelvis exposed for 3 to 4 cm. An approximately 2.5 x 3 cm long block of outer table was removed with an osteotome and cut into long strips to later place over the fracture site. Then abundant cancellous autograft was harvested with a curette. The wound was thoroughly irrigated and dry Gelfoam packed under pressure to ensure hemostasis. After satisfactory hemostasis was achieved, the fascia was closed with interrupted figure-of-eight 0 Vicryl stitches and the skin with buried 2-0 Vicryl and running 4-0 Monocryl subcuticular stitch. Dermabond was later applied to this wound.
Attention was then redirected to the posterior spine. The wound was thoroughly irrigated with bacitracin irrigation, followed by 3 liters of pulsatile irrigation. The posterior elements were decorticated with a high-speed bur, taking care to pay particular attention to the facet joints from T12 to L2. The rods were contoured to allow slight lordosis from T12 to L2 in order to reduce the fracture. The rods were secured with set screws and compression applied between the screws in order to further improve fracture alignment. AP and lateral fluoroscopic images confirmed satisfactory positioning of instrumentation and improvement of alignment. The long strips of bone graft were placed at the fracture site bilaterally, as the fracture was noted to exit through the pars on the left and through the pars and facet on the right. The remaining cancellous graft was placed generously over the posterior elements from T12 to L2. A medium Hemovac drain was placed below the fascia. The fascia was closed with 0 Vicryl figure-of-eight interrupted stitches, reinforced with 0 Vicryl running locked stitch. The subcutaneous tissues were closed with buried 2-0 Vicryl and the skin with staples. Sterile dressings were applied. He was able to move bilateral lower extremities to command and had no complaints of numbness, tingling or pain in his lower extremities. He had intact perineal sensation. There were no intraoperative complications. I was present and scrubbed for all key portions of the procedure.
OPERATION PERFORMED: Right L4-5 hemilaminectomy, foraminotomy, and diskectomy with microdissection.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and general endotracheal anesthesia was induced. She was given a gram of Ancef for infection prophylaxis. A Foley catheter was not used. The patient was turned into a prone position using a Wilson frame. The lumbar region was clipped and prepped with alcohol and DuraPrep. A midline incision was marked over L4-5. The area was infiltrated with 0.25% Marcaine with epinephrine. A midline incision was made and the right L4-5 level was exposed. Two x-rays were taken to confirm level localization. With the aid of an operating microscope, a right L4-5 hemilaminectomy was then performed using a Midas Rex drill. The ligamentum flavum was taken down. With microdissection, the L5 nerve root was identified and gently retracted medially. As expected from the MRI, a very large extruded disk fragment was found close to the midline lateralizing to the right at this level. The herniated material was removed mostly in a single fragment but with some additional free fragments as well. A small window was then made in the annulus, and a moderate amount of additional degenerated disk material was removed from within the disk space. A foraminotomy was also performed. Excellent decompression was achieved. All free fragments were carefully removed. The disk space and the wound were then thoroughly irrigated with antibiotic solution. A layer of DuraGen Plus was applied over the thecal sac. The wound was then closed in layers using 2-0 Vicryl and a subcuticular closure with Monocryl. Dermabond was applied on the skin. Additional infiltration with 0.25% Marcaine with epinephrine was used at the end of the procedure.
DATE OF OPERATION: MM/DD/YYYY
Right C7 radiculopathy with C6-7 herniated nucleus pulposus.
Right C7 radiculopathy with C6-7 herniated nucleus pulposus.
C6-7 anterior cervical discectomy; spinal cord decompression with microdissection technique; C6-7 anterior cervical fusion/arthrodesis with interbody bone allograft plus Osteofil and anterior cervical plating; intraoperative fluoroscopy and somatosensory-evoked potential monitoring.
SURGEON: John Doe, MD
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presented with evidence of a right C7 radiculopathy. She had undergone MRI of the cervical spine which showed evidence of a herniated disk at C6-7. The patient was treated with medical therapy. The symptoms persisted; however, because the patient’s symptoms were incapacitating and disabling, the risks and benefits of surgery as well as alternatives were duly discussed. The risks described regarding the above surgery include but were not limited to symptom persistence, worsening of symptoms, recurrence of disk herniation or radiculopathy, adjacent level disease, nonunion of fusion, bleeding, infection, spinal fluid leak, esophageal injury, recurrent laryngeal nerve injury, vascular injury to either the carotid or vertebral arteries, spinal cord injury resulting in paraplegia, quadriplegia, hemiparesis, numbness, weakness, paresthesias, bowel or bladder dysfunction or permanent disability. The potential need for future surgery was discussed, and the risks of general anesthesia were also reviewed including stroke, myocardial infarction, death, pulmonary embolus, pneumonia, ventilatory dependance. The procedure was described to the patient in layman's terms so that she may understand and then the patient provided informed consent and wished to proceed with surgery after all questions were answered.
DESCRIPTION OF OPERATION: On the day of surgery, the patient was brought to the preoperative holding area where IV access was obtained and mild IV sedation was administered. The patient was given prophylactic intravenous antibiotics and then was brought back to the operative suite. While on the hospital gurney, she underwent an uneventful induction of general anesthetic and placement of endotracheal tube. She was placed on the operating room table at this point in the supine position with her head placed in a gelatin roll and her neck slightly extended while placing a small roll between the shoulder blades. An x-ray was then obtained to evaluate the positioning of the cervical spine and it appeared to be anatomic. We then inspected all pressure points and padded them appropriately and secured her to the table. The patient was then given prophylactic Decadron. Baseline SSEP monitor leads were applied and baseline studies were obtained. Based on the intraoperative x-ray, we identified a crease in the patient's neck that correlated to a space over the C6-7 disk space and used that crease as our planned incision. We sterilely prepped the patient's neck at this time with Betadine scrub followed by 70% alcohol followed by povidone-iodine paint. We allowed the paint to dry, and once dried, we draped the area in the usual fashion. We infiltrated the planned incision and then used a #15 scalpel to incise the skin to the subcutaneous tissues. We undermined the soft tissues and then identified the platysma. We split the platysma parallel to its fibers to gain access to the deep structures of the neck. We developed a plane between the lateral surface of the neck being the sternocleidomastoid and carotid sheath along with the structures along the medial border of the neck including the strap muscles, esophagus and trachea. We dissected down this plane until we came down to the paraspinal cervical musculature. Once we identified the prevertebral soft tissues, a Cloward retractor was placed into the wound to retract the medial structures of the neck as well as the lateral structures of the neck. We used a Kitner dissector to dissect the longus colli musculature off of the anterior cervical spine. We placed a spinal needle into one of the disk spaces, obtained an x-ray and this was the C6-7 space. After confirming our level, we then used insulated monopolar electrocautery to remove the remaining longus and soft tissues off of the vertebral bodies at C6 and C7 as well as the intervening disk space. At this point, the Rainbow retractor was placed into the wound to maintain constant protection of the lateral and medial structures of the neck as well as to maintain visualization of the cervical spine. A #11 blade was used to incise the disk space and the anterior two-thirds of the disk material was removed. We then placed the Cloward distraction pins into the body of C6 and C7 and distracted the disk space slightly. We used a straight curette at this point to decorticate the endplates and then did the remainder of the procedure under microscopic visualization utilizing microdissection technique. We then used the Midas Rex drill and removed the remaining disk material down to the ligamentum flavum at the C6-7 disk space. Using microdissection technique, we used a micro nerve hook to develop a plane between the posterior longitudinal ligament and the cervical dura. Once this plane was developed, we used a combination of 1 and 2 mm Kerrisons to remove the ligamentum and to decompress the spinal cord. We did find a relatively large subligamentous free fragment of disk material towards the right side that was compressing the junction between the dura and the nerve root of C7 on the right side. When we removed this free segment, the thecal sac became much more relaxed, pulsatile and a small amount of epidural bleeding was seen. We controlled this bleeding with FloSeal. Once controlled, the FloSeal was removed. We continued to complete our diskectomy until the nerve roots were seen coming off bilaterally at this level. We passed the nerve hook out lateral along the foramen. No further compression was identified and passed the nerve hook both above and below the vertebral bodies of C6 and C7. Satisfied that we had completed the diskectomy and spinal decompression, at this point, we then fashioned a 7 mm cornerstone bone allograft into the disk space. We placed it approximately 1 mm recess relative to the anterior cervical spine and then relaxed our distraction pins. We removed our distraction pins and filled the holes with bone wax. We did fill the bone dowel with 1 mL of Osteofil for the interbody fusion. At this point, we then fashioned a 25 mm Atlantis Venture cervical plate spanning the C6 and C7 levels and placed a 4 x 15 mm self-drilling variable angled screw at C6 and two 4 x 15 mm screws at C7; those were fix screws. The screws were brought down until the locking mechanism was in place. We did obtain an x-ray that showed good alignment of our fusion construct. We then copiously irrigated the wound with antibiotic irrigation. We observed the wound for any additional bleeding; none was seen. The retractors were removed. The wound was irrigated once more and no additional bleeding was seen at that time. We then proceeded to close the platysma; it was closed with interrupted 3-0 nylon sutures as were the subcutaneous tissues in an inverted manner. The skin was closed using a running subcuticular 4-0 Vicryl suture and then was covered with Steri-Strips, Telfa gauze and paper tape. The estimated blood loss from the surgery was less than 50 mL. No complications occurred and SSEP monitor remained stable throughout surgery. At the end of the procedure, the patient was extubated and noted to be moving all her extremities. The patient was placed back on the hospital gurney and was taken to the recovery room.
OPERATION PERFORMED: Left frontotemporoparietal craniectomy and left frontal lobectomy with duraplasty.
DESCRIPTION OF OPERATION: The patient was brought to the operating room where he was induced under general anesthesia. He had already been intubated and was maintained on the ventilator. He was placed in the supine position with the head turned to the right, fixed in a Mayfield, and the left side of the head was shaved. A large question mark incision was marked on the left side of the head and the site was prepped and draped in the usual sterile fashion. The skin was incised, full thickness, with a #10 blade and hemostasis maintained with Raney clips. The scalp was elevated over the temporal fascia. The temporalis muscle and skin were then reflected over rolled 4 x 4 sponges and held in place with fishhooks. Four bur holes were placed in the frontotemporal bone and two in the parietal bone with dissection of the underlying dura with blunt instruments away from the inner table. Using a footplate drill bit on the Midas Rex drill, the craniotomy was opened using maximal exposure and then the bone thinned over the sphenoid wing. The craniotomy flap was then removed as a single piece. Additional bone was removed by thinning out the sphenoid wing and removing bone from the temporal side with the Leksell rongeur to extend our decompression down to the floor of the middle fossa. Bone wax was then applied to the bone edges for hemostasis. The dura remained very tense and so the dura was opened in a starburst pattern to allow expansion of the brain. It immediately herniated out beyond the level of the outer table of the skull and was noted to remain tense. After reviewing the CT scan, we felt that the temporal lobe appeared to remain viable but the frontal lobe was badly infarcted and we chose therefore to perform a frontal lobectomy. The pia of the frontal lobe was cauterized with bipolar cautery and opened with a 15 blade. By using suction, the anterior frontal lobe was then removed extending to the medial third near the midline and above the sylvian fissure. Necrotic tissue was easily removed and bleeding sites were cauterized with bipolar cautery. After we felt we had achieved an adequate decompression, the bed was lined with Surgicel and FloSeal for hemostasis. The entire brain was then irrigated with copious amounts of lactated Ringer's. The brain was then again inspected and our resection bed had good hemostasis. At this point, we began our closure. Several small pieces of EnDura graft were laid down over the brain to help expand the dura and the dura was then loosely closed down to the EnDura with 4-0 Vicryl sutures with all gaps covered by EnDura. The entire dural expansion closure was then covered with a large sheet of DuraGen. The fishhooks were removed and the galea was closed with 2-0 Vicryl sutures. The skin was then closed with skin staples. The wound was dressed with Telfa dressing, sponge and paper tape. No complications were encountered and the patient was left intubated for transported back to the NSICU in hemodynamically stable condition.
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