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Admission Date: November 15, 20XX Discharge Date: November 20, 20XX Description: The patient is a 49-year-old male who was admitted on November 15. He underwent revision laminectomy and stabilization of his lumbar spine with a Dynesys system. The patient tolerated the procedure well and had an uneventful hospital course, except experienced acute pain after the surgery requiring additional physical therapy and pain control. By postoperative day five, he was tolerating a regular diet, had obtained pain control, and cleared physical therapy. He was subsequently discharged home with written instructions. He is to follow up in three weeks after discharge. He was given Percocet and Flexeril for pain and spasms, as needed. History and Physical Admit Diagnosis: Recurrent herniated disc Procedure: Lumbar laminectomy, disc stabilization with Dynesys History of Present Illness: 49-year-old male with left leg and back pain. Diagnosed with recurrent disc herniation Past Medical History: Status post laminectomy and diskectomy two years ago Physical Examination Neck: Supple Heart: Regular rate and rhythm Lungs: Clear to auscultation Neuro: Left leg weakness, numbness, and pain Skin: No lesions, masses, or rashes Assessment and Plan: Recurrent HNP L5 to S1 Operative Report Preoperative Diagnosis: Radiculopathy and degenerative disc disease at L5-S1 with recurrent disc herniation at L5-S1 Postoperative Diagnosis: Same Procedure Performed: Revision L5 laminectomy, revision S1 laminectomy and diskectomy, stabilization of L5 to S1 with flexible rod Dynesys system Anesthesia: General Blood Loss: Minimal Complications: Intraoperative dural tear, which was repaired with watertight seal with interrupted 4-0 Nurolon sutures Description of the Procedure: Under sterile conditions, the patient was brought to the operating room and was placed under general endotracheal anesthesia and placed in a prone position. Lumbar spine was then prepped and draped in the usual sterile manner with a Betadine prep. A lateral x-ray was obtained with an 18-gauge spinal needle placed for level localization. Based upon the x-ray, a direct posterior approach to the lumbar spine was performed. This was carried down to the transverse process of L5 and the sacral ala bilaterally. After adequate exposure, partial laminectomy was performed in a subperiosteal fashion with a combination Leksell and Kerrison rongeurs at the L5 and S1 levels. Mobilization of the left S1 and L5 nerve roots was performed, although there was a significant amount of scar tissue. There was a large free L5-S1 recurrent disc fragment, which was removed with a pituitary rongeur. There was a small dural tear within the axilla of the L5 nerve root repaired with watertight seal with interrupted 4-0 Nurolon sutures. After adequate decompression, attention was brought to stabilization. Using the usual internal and external landmarks, pedicle screws were placed in the L5 and S1 pedicles bilaterally. These were drilled, probed, dilated, and then a combination of 7.2 mm × 40 mm screws and 7.2 mm × 45 mm screws were placed in the L5 and S1 pedicles bilaterally. AP and lateral x-rays were obtained, noting appropriate placement of the screws. Measuring of the cord device was performed bilaterally. The cord was placed in the usual fashion, tensioned, and then finally tightened. The wound was copiously irrigated with bacitracin solution. No drain was ­utilized. The fascia was closed with interrupted 0 Vicryl suture. The subcutaneous tissue and skin were closed in three sequential layers. The patient was awakened in the operating room, extubated, and brought to the recovery room in satisfactory condition. Code Assignment Including POA Indicator ICD

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