Jessica Williams, jazz pianist

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DICTATED MEDICAL REPORT

SWEDISH HOSPITAL

Notes/Transcription

Pre-op Diagnosis: L4-S1 stenosis and DDD

Post-op Diagnosis: L4-S1 stenosis and DDD

Anesthesia: General endotracheal

Operative Findings: degenerative changes at L4-S1, stenosis.

Indications: Pt had failed nonsurgical management and did not want to risk narcotic addiction to manage her symptoms.

She has had previous laminectomies at L5-S1 in the past and now has persistent radiculopathy from a recurrent or persistent disc herniation at L5-S1 on the right. She also has loss of height from collapse of the disc which contributes to her foraminal stenosis at both levels. She has loss of disc height which contributes to her hyperlordosis and postural kyphosis deformity.

PROCEDURES

1. L5-S1 posterior interbody fusion and posterior fusion .

2. L4-5 lateral extracavitary arthrodesis

3. L4-L5-S1 pedicle screws.

4. Posterior posterolateral fusion, L4-5.

5. Smith-Peterson osteotomy, L4-5 and L5-S1 .

6. Neuroplasty, adhered nerve root, L5-S1.

7. lnterbody cage, L4-5 and L5-S1.

8. Bipedicled paraspinal trunk flap

9. 3 Laminectomies with foraminotomies and medial facetectomy L4-5

DESCRIPTION OF OPERATION

After consent was obtained, the patient was taken to the OR, anesthetized, Foley was placed, intraoperative monitoring electrodes and SCDs were all placed.

The patient was placed on a Jackson table in the prone position with all of her bony prominences padded.

The patient was prepped and draped in typical sterile fashion.

A standard posterior dissection was done at the lumbosacral interval from L4- to S1 from the tips of the transverse processes to the sacral ala. A C arm was used to confirm the correct level.

At L5-S1, through a minimal laminotomy, a discectomy for fusion was performed on the right side and an interbody and posterior arthrodesis was performed.

Hand instruments and a burr were used.

The cartilage endplate was decorticated to establish bleeding subchondral bone.

Morselized autograft and a PEEK cage was placed into the interbody space and the posterolateral gutter for the fusion substrate.

The previous adhesions from the previous laminectomies at L5-S1 remained a problem.

The arachnoid adhesions were then released by performing a neuroplasty out lateral to the confines of the bony portion of the spinal column to establish freely mobile lumbar nerve roots.

Because this was lateral to the foramen and outside the bony canal, it was the lumbar plexus origin.

The posterior elements of L5-S1 were then resected with osteotomes and a burr in a manner described as a Smith Peterson osteotomy so that physiologic lordosis could be induced into the fusion contruct.

Tl1is was required because distraction of the disc space to put a cage in from the back induced kyphosis at the L5-S1 motion segment. The posterior elements did not allow compression and lordosis without the osteotomy.

At L4-5, through a lateral extracavitary approach, an arthrodesis was performed on the right side.

Hand instruments and a burr were used. The far lateral dissection required dissection into the retroperitoneal space and retraction of those tissues.

This was more involved since it required dissecting the paraspinal muscles down to the lateral side of the vertebral body.

This allowed us to access the disc space with no retraction on the thecal sac.

The cartilage endplate was decorticated to establish bleeding subchondral bone.

Morselized autograft and a PEEK cage was placed into the interbody space for the fusion substrate.

Because the minimal laminotomy was inadequate to decompress the nerve roots, since it was so far lateral, a laminectomy with bilateral foraminotomies and facetectomies was then performed by removing the osseous confines of the of the lateral recess and foramen laterally.

This was accomplished with a combination hand instruments and a burr and done bilaterally.

The posterior elements of L4-5 were then resected with osteotomes and a burr in a manner described as a Smith Peterson osteotomy so that physiologic lordosis could be induced into the fusion contruct.

Pedicle screws were then placed bilaterally at L4, L5, and S1 using standard technique.

The implant position was then confirmed with the C arm and intraoperative monitoring was used to test the screws which were all within normal limits.

The posterior elements were decorticated with a burr and the remaining autograft was used for the posterior and inter transverse fusion at L4-5.

Due to the soft tissue contractures from the previous lumbar surgery, the typical manner of closing the wound by suturing the fascial layer and subcutaneous tissues was impossible.

Therefore a bipedicled paraspinal muscle trunk flap was developed.

This was done by releasing the contracted and fibrotic dorsal lumbar fascia off the midline which allowed it to be mobilized to the midline and closed without tension on the suture layer that was used to bring it to the midline and roll the muscle belly into the wound defect obliterating the dead space in the midline. #1 Vicryl suture was used for the flap.

The rest of the wound was then closed in multiple layers over a deep fascial drain.

0 and 2-0 Vicryl suture was used for this portion and the skin was closed with a running nylon suture.

The patient was placed in a sterile dressing and recovered uneventfully.

END OF REPORT

Printed on 8/13/2012 5:59 PM

Swedish Medical 2B 8/13/2012 6:08:10 PM PAGE 20/0?2 Fax Server

FIRST HILL 747 Broadway Seattle, WA 98122-4307

W ILLIAMS,JESSICA MRN: 1000327822

DOB: 3/17/1948, Sex: F

SWEDISH

Notes/Transcription (continued)

D/C Summaries signed by Morrow, Darin F, PA┬ĚC at 07/30i12 0704

Autr1or: Morrow, Darin F, PA- Service: (none) ,1\uthor Type: Physician Assistant

Filed: 07/30/12 0704 Note 07/30/12 0700 Note Type: D/C Summaries

Time: Cosign Rooney, Richard C, er: MD at 07/30/12 0811

DISCHARGE SUMMARY Darin F Morrow, PA-C

This note must be assigned Note Type "D/C Summaries" to be searchable

Jessica Jennifer Williams

Age/Gender 64 y.o. female

MRN 1000327822

Attending Rooney, Richard C, MD

PCP Shalit, Peter

Hospital Problem List Active Problems:

No active hospital problems.

Final Diagnosis: Lumbar spinal stenosis and DJD L4-S1

Procedures Completed:

1. L5-S1 posterior interbody fusion and posterior fusion .

2. L4-5 lateral extracavitary arthrodesis

3. L4-L5-S1 pedicle screws.

4. Posterior posterolateral fusion, L4-5.

5. Smith-Peterson osteotomy, L4-5 and L5-S1 .

6. Neuroplasty, adhered nerve root, L5-S1.

7. lnterbody cage, L4-5 and L5-S1.

8. Bipedicled paraspinal trunk flap

9. 3 Laminectomies with foraminotomies and medial facetectomy L4-5

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(sounds like it hurts - JW)

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