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OPERATION REPORT SEX: MALE AGE: 56 DATE OF OPERATION: 01/1/20XX PREOPERATIVE DIAGNOSIS: LEFT L3-4 HERNIATED DISC WITH RADICULOPATHY. POSTOPERATIVE DIAGNOSIS: LEFT L3-4 HERNIATED DISC WITH RADICULOPATHY. PROCEDURES: MINIMALLY INVASIVE LEFT-SIDED L3-4 INTRALAMINAR LAMINOTOMY, MEDIAL FACETECTOMY AND DISCECTOMY. SURGEON: Hank Andrews, MD ESTIMATED BLOOD LOSS: LESS THAN 50 CC. INDICATIONS: The patient is a male who is referred to the neurosurgery clinic for management of intractable pain in the left leg. The pain followed the L3-4 dermatomal distribution and after having failed conservative care, an MRI was done that revealed a herniated disc at L3-4 level on the left. This disc herniation was impinging upon the exiting nerve and correlated well with his symptoms. I recommended performing a discectomy and decompression of the nerve root. The procedure along with its risks, possible benefits and possible complications were explained to the patient to his understanding and his questions were answered to his satisfaction. Surgical and nonsurgical alternatives were discussed and he consented to the operation as described after his questions were answered to his satisfaction. PROCEDURE: The patient was brought into the operating room and while on the stretcher general anesthesia was induced and he was endotracheally intubated. He was subsequently transferred to the Jackson table in the prone position where the surgical site was shaved, prepped and draped in the usual fashion. Using AP and lateral fluoroscopy, the site of the incision on the left side of the spine immediately overlying the L3-4 disc was identified and marked. With a #10-scalpel a transverse incision was made overlying the L3-4 disc on the left side. Subsequently using AP and lateral fluoroscopy, a guidewire and subsequently a series of progressively larger dilators were introduced through the incision into the space immediately overlying the medial facet and lamina. In this fashion a retraction tunnel was created through the paravertebral muscle through which the operation was done. A tube retractor was introduced around the distractors attached to the table in standard fashion and the distractors were then removed. The positioning of the tube retractor was then confirmed using AP and lateral fluoroscopy. The operating microscope was brought into the field and the remaining part of the surgery was done under magnification. A small amount of muscle still overlying the lamina and facet was carefully coagulated with unipolar cautery and retracted out of the way. With an air drill, the bony structures identified were carefully drilled in order to perform a lateral laminectomy and medial facetectomy. This was done with great care not to penetrate the underlying ligamentum flavum. The remaining part of the laminotomy was then performed with the use of small Kerrison rongeurs. The ligamentum flavum was elevated with a nerve hook and subsequently divided sharply. It was resected with a Kerrison rongeur to expose the underlying thecal sac and nerve root. Tissues lateral to the nerve root were coagulated with bipolar cautery and in doing this, the disc herniation came into view. It was seen to be bulging against the nerve root and compressing it eventually. The annulus was incised sharply and disc material was removed from within the intervertebral disc space. In doing so the annulus and posterior longitudinal ligament was flattened out and retracted away from the nerve root next to it. Any remaining disc fragments were carefully pushed into the intervertebral disc space and removed with pituitary forceps. At this point, the nerve root was adequately decompressed thus was the foramen. Hemostasis from epidural tissues was obtained with bipolar cautery. The entire surgical site was irrigated with warm saline and the dura and nerve were inspected for the possibility of any dural tears. No such tears were found, so we proceed at this point with the closure. The epidural space was filled with Depo-Medrol suspension and covered with a thin layer of Gelfoam. The retractor was removed under direct vision and any bleeding of the muscle along the way was carefully coagulated with bipolar cautery. The closure was performed by reapproximating the fascia with 3-0 Vicryl and subcutaneous tissues with the same. Skin edges were brought back together with a running subcuticular layer of 4-0 Monocryl. The incision was then cleaned with Betadine and a sterile dressing was applied in usual fashion. At this point, the patient was transferred to the stretcher in the supine position where anesthesia was reversed and he was extubated. Upon extubation, he was sleepy but arousable. He was following simple commands and he was moving all his extremities without any evidence of weakness. The patient tolerated the procedure well and there were no intraoperative complications. At this point, the patient was transferred to the recovery room in stable condition for further monitoring.

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