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Operative Report, Laminotomies and Foraminotomies LOCATION: Inpatient, Hospital PATIENT: Todd Osmond ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Herniated disc L3-4 (third lumbar vertebra- fourth) on the right and the left POSTOPERATIVE DIAGNOSIS: Herniated disc L3-4 on the right and the left PROCEDURE PERFORMED: Bilateral laminotomies and foraminotomies at L3-4 with removal of the disc from the right and left side. Application of an allograft, 2.5 cc (cubic centimeter) on each side. ANESTHESIA: General PROCEDURE: The patient was placed in a prone position. The back was prepped and draped in the usual manner. The previous incision was incised. The erector spinae muscles were dissected from the lamina. About three or four retractors were placed in the wound. We isolated the L3-4 interspace via x-ray. Laminotomies were performed with foraminotomies on the left and the right side. The ligamentum flavum was very hypertrophic. The facets were hypertrophic. We took these down. Retracted on the nerve root and got the disc space. Here is what happened on the left side: There was a disc material on the body of L4. I took this down, went into the disc space, and removed much degenerating material. On the right side, I did the same thing. The disc here was on the body of L3. We took it down, took the midline fragments down. I was satisfied that I had cleaned out the disc space. There was no compression on the nerve roots. Passed a hockey stick up and medially and down and medially into the foramen. The dura was well compressed. Irrigated the wound well. After this, we then put Gleotec about 2.5 cc on the right and on the left side. No drains were utilized. The lumbodorsal fascia was approximated with double knotted 0 chromic, 0 Vicryl as well, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the PAR (postanesthesia recovery). SERVICE CODE(S): _______________________________________ ICD-10-CM DX CODE(S): __________________________________

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