OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:  Back and leg pain with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Bilateral L4/5, and L5/S1 facet hypertrophy, facet arthropathy, and degenerative disc disease, lateral recess stenosis due to ligamentum flavum hypertrophy, lumbar herniated disc, and upward migration of the superior articular process entrapping the exiting and traversing nerve root causing spinal stenosis claudication symptoms.

 

POSTOPERATIVE DIAGNOSIS:  Bilateral L4/5, and L5/S1 facet hypertrophy, facet arthropathy, and degenerative disc disease, lateral recess stenosis due to ligamentum flavum hypertrophy, lumbar herniated disc, and upward migration of the superior articular process entrapping the exiting and traversing nerve root causing spinal stenosis claudication symptoms.

 

PROCEDURES: Bilateral midline posterior L4/5, and L5/S1 laminoforaminotomy  with rhizotomy via medial and lateral branch neurectomy of the L4/5, and L5/S1 facet joints with all procedures utilizing continuous radiofrequency heating each site to a minimum of 60 degrees Celsius for a minimum of 90 seconds each UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE through two separate skin and fascial incisions on both sides.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Facet arthropathy, foraminal and lateral recess stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

 

PROCEUDRES LEFT-SIDED LOCAL ANESTHESIA AND RHIZOTOMY VIA OPEN SKIN INCISION IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the L3/4, L4/5, and L5/S1 facet joint complex,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  L3/4 Medial Branch and Facet Block

4.                  L4/5 Medial Branch and Facet Block

5.                  L5/S1 Medial Branch and Facet Block

6.                  Direct and continuous visualization of the L4/5  facet joint complex with rhizotomy of the L4/5 facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

7.                  Direct and continuous visualization of the L5/S1  facet joint complex with rhizotomy of the L5/S1 facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

 

PROCEDURES LEFT LATERAL RECESS DECOMPRESSION VIA SEPARATE INCISION:

1.                  Laminotomy  through separate left-sided skin and fascial incisions L4/5 with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

2.                  Laminotomy  through separate left-sided skin and fascial incisions L5/S1 with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

 

 

PROCEUDRES RIGHT-SIDED LOCAL ANESTHESIA AND RHIZOTOMY VIA OPEN SKIN INCISION IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the L3/4, L4/5, and L5/S1 facet joint complex,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  L3/4 Medial Branch and Facet Block

4.                  L4/5 Medial Branch and Facet Block

5.                  L5/S1 Medial Branch and Facet Block

6.                  Direct and continuous visualization of the L4/5  facet joint complex with rhizotomy of the L4/5 facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

7.                  Direct and continuous visualization of the L5/S1  facet joint complex with rhizotomy of the L5/S1 facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

 

PROCEDURES RIGHT LATERAL RECESS DECOMPRESSION VIA SEPARATE INCISION:

1.                  Laminotomy  through separate left-sided skin and fascial incisions L4/5 with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

2.                  Laminotomy  through separate left-sided skin and fascial incisions L5/S1 with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

 

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the decompression, and rhizotomy, radiofrequency ablation procedure through separate fascial and skin incions for the laminotomy and rhizotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and posterior thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from lumbar radiculopathy and lumbar Facet Joint Dysfunction Pain Syndrome with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 12 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective bilateral L4-S1 midline posterior decompression and rhizotomy procedure under continuous direct visualization of the spine.

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors bilaterally at L4/5, and L5/S1, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed bilaterally at L4/5, and L5/S1 during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent L3/4 level to address cross-innervation. 

 

On the RIGHT SIDE THE DIRECT POSTERIOR DECOMPRESSION was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically at both levels. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the respective laminae starting of its inferior margin and partial removal of the medial facet joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the LEFT SIDE THE DIRECT POSTERIOR DECOMPRESSION was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically at both levels. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the respective laminae starting of its inferior margin and partial removal of the medial facet joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On both sides, these maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.

 

For the RIGHT-SIDED RHIZOTOMY portion of the procedure, a tubular retractor system was placed through a  separate skin incisions at the L4, and L5 transverse process of the L4/5, and L5/S1 facet joint.  The medial and lateral branches were directly and continuously visualized, and a neurectomy was performed by dissecting and and ablating the medial and lateral branch with continuous, non-pulsed radiofrequency heating local tissues to over 60 degrees Celsius for a minimum of 90 seconds per site.

 

For the LEFT-SIDED RHIZOTOMY portion of the procedure, a tubular retractor system was placed through a  separate skin incisions at the L4, and L5 transverse process of the L4/5, and L5/S1 facet joint.  The medial and lateral branches were directly and continuously visualized, and a neurectomy was performed by dissecting and and ablating the medial and lateral branch with continuous, non-pulsed radiofrequency heating local tissues to over 60 degrees Celsius for a minimum of 90 seconds per site.

 

At the end of the case, the traversing root(s) were adequately decompressed and visualized.  There was no evidence of dural leakage.  The surgical sites were checked for hemostasis.  Forty mg of Depomedrol were injected epidurally for reduction of postoperative symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  A surgical dressing was applied.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD

 

OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:   Back and bilateral leg pain with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Symptomatic bilateral lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) bilaterally.

 

POSTOPERATIVE DIAGNOSIS:  Sympotmatic bilateral lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) bilaterally.

 

PROCEDURES: Bilateral midline posterior and bilateral Transforaminal Decompression LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE through two separate skin and fascial incisions on both sides (four incisions) bilaterally.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Foraminal and Lateral Recess Stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

PROCEUDRES LOCAL ANETHESTHESIA FOR BILATERAL INCISIONS IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) neuroforamen,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  LUMBAR X-1 / LUMBAR Y-1 (INCLUDES SACRAL 1-1 IF SELECTED) Medial Branch Block

4.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Medial Branch Block

5.                  LUMBAR X-1 / LUMBAR Y-1 (INCLUDES SACRAL 1-1 IF SELECTED) Facet Block

6.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Facet Block

 

PROCEDURES POSTERIOR DECOMPRESSION RIGHT SIDE IN DETAIL:

1.                    Laminotomy LUMBAR X on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the surgical side through separate skin and fascial incision

 

PROCEDURES TRANSFORAMINAL DECOMPRESSION RIGHT SIDE IN DETAIL:

1.                  Partial  resection of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  vertebral body by removal of bone from the superior articular process of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) through a separate lateral skin and facial incision

2.                  Partial  resection of LUMBAR X vertebral body by removal of bone from the inferior articular process of LUMBAR X  through a separate lateral skin and facial incision

3.                  Tranforaminal Microdiscectomy at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)

 

PROCEDURES POSTERIOR DECOMPRESSION LEFT SIDE IN DETAIL:

1.                    Laminotomy LUMBAR X on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the surgical side through separate skin and fascial incision

 

PROCEDURES TRANSFORAMINAL DECOMPRESSION LEFT SIDE IN DETAIL:

1.                  Partial  resection of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  vertebral body by removal of bone from the superior articular process of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) through a separate lateral skin and facial incision

2.                  Partial  resection of LUMBAR X vertebral body by removal of bone from the inferior articular process of LUMBAR X  through a separate lateral skin and facial incision

3.                  Tranforaminal Microdiscectomy at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)

 

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the combined midline and transforaminal bilateral single level decompression procedure through two separate fascial incions on each side. Thus, a total of 4 separate skin and fascial incisions were made:  on each side a mideline paraspinal incision for the laminotomy part of the procedure, and a lateral paraspinal incision for the foraminotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time which in the case the patient has been going on for several months.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from lumbar radiculopathy with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 6 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective bilateral midline posterior and lateral transforaminal decompression LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) under continuous direct visualization of the spine.

 

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent levels to address cross-innervation. 

 

On the right side the direct posterior decompression was done via a hemilaminotomy and the lateral recess was decompressed surgically. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial fect joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the right side the transforaminal foraminotomy decompression was done via sequentially larger reamers that were introduced into the neuroforamen with constant monitoring of the patients motor function in the lower extremity on the surgical side.   The reaming allowed partial resection of the superior and inferior articular process at the surgical level.  The decompression of the neural elements was further aided by removal of the hypertrophic superior and inferior articular process using power drills.  A 3-0 Kerrison rongeur was also used during this portion of the procedure.   A continuous radiofrequency probe was used to achieve hemostasis.  An osteotome was used to perform a partial corpectomy with removal of  a section of the posterior vertebral body to surgically release the traversing and exiting nerve roots that were entrapped under the facet complex due to significant hypertrophy of the facet joints as well as the ring apophysis of the superior and inferior vertebral bodies at the surgical level.   In addition to a microdiscectomy, a partial pediculectomy was performed on the inferior pedicle of the surgical level to adequately decompress the traversing nerve root as well.  The vertebral osteotomy, and partial facet resection produced a significant increase in the neuroforaminal volume. 

 

On the left side the direct posterior decompression was done via a hemilaminotomy and the lateral recess was decompressed surgically in a similar manner under continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial fect joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the left side the transforaminal foraminotomy decompression was done via sequentially larger reamers that were introduced into the neuroforamen with constant monitoring of the patients motor function in the lower extremity on the surgical side.   The reaming allowed partial resection of the superior and inferior articular process at the surgical level.  The decompression of the neural elements was further aided by removal of the hypertrophic superior and inferior articular process using power drills.  A 3-0 Kerrison rongeur was also used during this portion of the procedure.   A continuous radiofrequency probe was used to achieve hemostasis.  An osteotome was used to perform a partial corpectomy with removal of  a section of the posterior vertebral body to surgically release the traversing and exiting nerve roots that were entrapped under the facet complex due to significant hypertrophy of the facet joints as well as the ring apophysis of the superior and inferior vertebral bodies at the surgical level.   In addition to a microdiscectomy, a partial pediculectomy was performed on the inferior pedicle of the surgical level to adequately decompress the traversing nerve root as well.  The vertebral osteotomy, and partial facet resection produced a significant increase in the neuroforaminal volume. 

 

On both sides, these maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.  No additional free fragments or residual bony pathology that could further impinge spinal elements were found.

 

At the end of the case, 40 mg of Depomedrol were injected epidurally for postoperative reduction of symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  Intermil was applied as a dressing.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD

 

OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:   Back and SELECT SIDE sided leg pain with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Symptomatic lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the SELECT SIDE.

 

POSTOPERATIVE DIAGNOSIS:  Sympotmatic lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the SELECT SIDE.

 

PROCEDURES: Midline Posterior and Lateral Transforaminal Decompression LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE on the SELECT SIDE side.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Foraminal and Lateral Recess Stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus on the SELECT SIDE at the LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) level.

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

PROCEUDRES LOCAL ANETHESTHESIA IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) neuroforamen,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  LUMBAR X-1 / LUMBAR Y-1 (INCLUDES SACRAL 1-1 IF SELECTED) Medial Branch Block

4.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Medial Branch Block

5.                  LUMBAR X-1 / LUMBAR Y-1 (INCLUDES SACRAL 1-1 IF SELECTED) Facet Block

6.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Facet Block

 

PROCEDURES POSTERIOR DECOMPRESSION IN DETAIL:

1.                    Laminotomy LUMBAR X on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the surgical side through separate skin and fascial incision

 

PROCEDURES TRANSFORAMINAL DECOMPRESSION IN DETAIL:

1.                  Partial  resection of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  vertebral body by removal of bone from the superior articular process of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) through a separate lateral skin and facial incision

2.                  Partial  resection of LUMBAR X vertebral body by removal of bone from the inferior articular process of LUMBAR X  through a separate lateral skin and facial incision

3.                  Tranforaminal Microdiscectomy at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)

 

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the combined midline and transforaminal unilateral single level decompression procedure through two separate fascial incions: a mideline paraspinal incision for the laminotomy part of the procedure, and a lateral paraspinal incision for the foraminotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time which in the case the patient has been going on for several months.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from lumbar radiculopathy with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 6 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective midline posterior and lateral transforaminal decompression LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) under continuous direct visualization of the spine on the SELECT SIDE side.

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent levels to address cross-innervation. 

 

For the direct posterior decompression, a hemilaminotomy was performed and the lateral recess was decompressed surgically. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial fect joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

For the transforaminal foraminotomy decompression, sequentially larger reamers were introduced into the neuroforamen with constant monitoring of the patients motor function in the lower extremity on the surgical side.   The reaming allowed partial resection of the superior and inferior articular process at the surgical level.  The decompression of the neural elements was further aided by removal of the hypertrophic superior and inferior articular process using power drills.  A 3-0 Kerrison rongeur was also used during this portion of the procedure.   A continuous radiofrequency probe was used to achieve hemostasis.  An osteotome was used to perform a partial corpectomy with removal of a section of the posterior vertebral body to surgically release the traversing and exiting nerve roots that were entrapped under the facet complex due to significant hypertrophy of the facet joints as well as the ring apophysis of the superior and inferior vertebral bodies at the surgical level.   In addition to a microdiscectomy, a partial pediculectomy was performed on the inferior pedicle of the surgical level to adequately decompress the traversing nerve root as well.  The vertebral osteotomy, and partial facet resection produced a significant increase in the neuroforaminal volume. 

 

These maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.  No additional free fragments or residual bony pathology that could further impinge spinal elements were found.

 

At the end of the case, 40 mg of Depomedrol were injected epidurally for postoperative reduction of symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  Intermil was applied as a dressing.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD

 

OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:   Back and bilateral leg pain with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Symptomatic bilateral lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) bilaterally.

 

POSTOPERATIVE DIAGNOSIS:  Sympotmatic bilateral lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  bilaterally.

 

PROCEDURES: Bilateral midline posterior and bilateral Transforaminal Decompression LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE through two separate skin and fascial incisions on both sides (four incisions) bilaterally.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Foraminal and Lateral Recess Stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

PROCEUDRES LOCAL ANETHESTHESIA FOR BILATERAL INCISIONS IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) neuroforamen,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  LUMBAR A-1 / LUMBAR B-1 Medial Branch Block

4.                  LUMBAR A / LUMBAR B Medial Branch Block

5.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Medial Branch Block

6.                  LUMBAR A-1 / LUMBAR B-1 Facet Block

7.                  LUMBAR A / LUMBAR B Facet Block

8.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Facet Block

 

PROCEDURES POSTERIOR DECOMPRESSION RIGHT SIDE IN DETAIL:

1.                    Laminotomy LUMBAR A on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR A / LUMBAR B  on the surgical side through separate skin and fascial incision,

2.                    Laminotomy LUMBAR X on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the surgical side through separate skin and fascial incision

 

PROCEDURES TRANSFORAMINAL DECOMPRESSION RIGHT SIDE IN DETAIL:

1.                  Partial  resection of LUMBAR B  vertebral body by removal of bone from the superior articular process of LUMBAR B through a separate lateral skin and facial incision

2.                  Partial  resection of LUMBAR A vertebral body by removal of bone from the inferior articular process of LUMBAR A through a separate lateral skin and facial incision

3.                  Tranforaminal Microdiscectomy at LUMBAR A / LUMBAR B.

4.                  Partial  resection of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  vertebral body by removal of bone from the superior articular process of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) through a separate lateral skin and facial incision

5.                  Partial  resection of LUMBAR X vertebral body by removal of bone from the inferior articular process of LUMBAR X  through a separate lateral skin and facial incision

6.                  Tranforaminal Microdiscectomy at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)

 

PROCEDURES POSTERIOR DECOMPRESSION LEFT SIDE IN DETAIL:

1.                    Laminotomy LUMBAR A on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR A / LUMBAR B  on the surgical side through separate skin and fascial incision,

2.                    Laminotomy LUMBAR X on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the surgical side through separate skin and fascial incision

 

PROCEDURES TRANSFORAMINAL DECOMPRESSION LEFT SIDE IN DETAIL:

1.                  Partial  resection of LUMBAR B  vertebral body by removal of bone from the superior articular process of LUMBAR B through a separate lateral skin and facial incision

2.                  Partial  resection of LUMBAR A vertebral body by removal of bone from the inferior articular process of LUMBAR A through a separate lateral skin and facial incision

3.                  Tranforaminal Microdiscectomy at LUMBAR A / LUMBAR B.

4.                  Partial  resection of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  vertebral body by removal of bone from the superior articular process of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) through a separate lateral skin and facial incision

5.                  Partial  resection of LUMBAR X vertebral body by removal of bone from the inferior articular process of LUMBAR X  through a separate lateral skin and facial incision

6.                  Tranforaminal Microdiscectomy at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the combined midline and transforaminal bilateral multilevel decompression procedure through a minimum of two separate fascial incions on each side. Thus, a minimum of 4 separate skin and fascial incisions were made in total:  on each side a mideline paraspinal incisions for the laminotomy part of the procedure, and a lateral paraspinal incisions for the foraminotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time which in the case the patient has been going on for several months.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from lumbar radiculopathy with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 6 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective bilateral midline posterior and lateral transforaminal decompression LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) under continuous direct visualization of the spine.

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent levels to address cross-innervation. 

 

On the right side, the direct posterior decompression was done for both levels via a hemilaminotomy and the lateral recess was decompressed surgically at each individual level. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial fect joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the right side, the transforaminal foraminotomy decompression was done for both levels via sequentially larger reamers that were introduced into the neuroforamen with constant monitoring of the patients motor function in the lower extremity at each level.   The reaming allowed partial resection of the superior and inferior articular process at the surgical levels.  The decompression of the neural elements was further aided by removal of the hypertrophic superior and inferior articular process using power drills.  A 3-0 Kerrison rongeur was also used during this portion of the procedure.   A continuous radiofrequency probe was used to achieve hemostasis.  An osteotome was used to perform a partial corpectomy with removal of  a section of the posterior vertebral body to surgically release the traversing and exiting nerve roots that were entrapped under the facet complex due to significant hypertrophy of the facet joints as well as the ring apophysis of the superior and inferior vertebral bodies at the surgical level.   In addition to a microdiscectomy, a partial pediculectomy was performed on the inferior pedicle of the surgical level to adequately decompress the traversing nerve root as well.  The vertebral osteotomy, and partial facet resection produced a significant increase in the neuroforaminal volume. 

 

On the left side, the direct posterior decompression was done for both levels via a hemilaminotomy and the lateral recess was decompressed surgically at each individual level. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial fect joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the left side, the transforaminal foraminotomy decompression was done for both levels via sequentially larger reamers that were introduced into the neuroforamen with constant monitoring of the patients motor function in the lower extremity at each level.   The reaming allowed partial resection of the superior and inferior articular process at the surgical levels.  The decompression of the neural elements was further aided by removal of the hypertrophic superior and inferior articular process using power drills.  A 3-0 Kerrison rongeur was also used during this portion of the procedure.   A continuous radiofrequency probe was used to achieve hemostasis.  An osteotome was used to perform a partial corpectomy with removal of  a section of the posterior vertebral body to surgically release the traversing and exiting nerve roots that were entrapped under the facet complex due to significant hypertrophy of the facet joints as well as the ring apophysis of the superior and inferior vertebral bodies at the surgical level.   In addition to a microdiscectomy, a partial pediculectomy was performed on the inferior pedicle of the surgical level to adequately decompress the traversing nerve root as well.  The vertebral osteotomy, and partial facet resection produced a significant increase in the neuroforaminal volume.

 

On both sides and both levels, these maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.  No additional free fragments or residual bony pathology that could further impinge spinal elements were found.

 

At the end of the case, 40 mg of Depomedrol were injected epidurally for postoperative reduction of symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  Intermil was applied as a dressing.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD

 

OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:   Back and leg pain on the SELECT SIDE side with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Symptomatic multilevel lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the SELECT SIDE.

 

POSTOPERATIVE DIAGNOSIS:  Sympotmatic multilevel lumbar spinal foraminal and lateral recess stenosis with HNP, ligamentum flavum hypertrophy, and facet hypertrophy LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the SELECT SIDE.

 

PROCEDURES: Bilateral midline posterior and bilateral Transforaminal Decompression LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE through two separate skin and fascial incisions on both sides (four incisions) on the SELECT SIDE side.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Foraminal and Lateral Recess Stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

PROCEUDRES LOCAL ANETHESTHESIA FOR SELECT SIDE SIDED INCISIONS IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the LUMBAR A / LUMBAR B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) neuroforamen,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  LUMBAR A-1 / LUMBAR B-1 Medial Branch Block

4.                  LUMBAR A / LUMBAR B Medial Branch Block

5.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Medial Branch Block

6.                  LUMBAR A-1 / LUMBAR B-1 Facet Block

7.                  LUMBAR A / LUMBAR B Facet Block

8.                  LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) Facet Block

 

PROCEDURES POSTERIOR DECOMPRESSION SELECT SIDE SIDE IN DETAIL:

1.                    Laminotomy LUMBAR A on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR A / LUMBAR B  on the surgical side through separate skin and fascial incision,

2.                    Laminotomy LUMBAR X on the surgical side with removal of the inferior lamina to complete hemilaminotomy with removal of lamina, ligamentum flavum  microdiscectomy through midline, paraspinal approach at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) on the surgical side through separate skin and fascial incision

 

PROCEDURES TRANSFORAMINAL DECOMPRESSION SELECT SIDE SIDE IN DETAIL:

1.                  Partial  resection of LUMBAR B  vertebral body by removal of bone from the superior articular process of LUMBAR B through a separate lateral skin and facial incision

2.                  Partial  resection of LUMBAR A vertebral body by removal of bone from the inferior articular process of LUMBAR A through a separate lateral skin and facial incision

3.                  Tranforaminal Microdiscectomy at LUMBAR A / LUMBAR B.

4.                  Partial  resection of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)  vertebral body by removal of bone from the superior articular process of LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) through a separate lateral skin and facial incision

5.                  Partial  resection of LUMBAR X vertebral body by removal of bone from the inferior articular process of LUMBAR X  through a separate lateral skin and facial incision

6.                  Tranforaminal Microdiscectomy at LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED)

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the combined midline and transforaminal bilateral single level decompression procedure through two separate fascial incions on each side. Thus, a total of 4 separate skin and fascial incisions were made:  on each side a mideline paraspinal incision for the laminotomy part of the procedure, and a lateral paraspinal incision for the foraminotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time which in the case the patient has been going on for several months.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from multilevel lumbar radiculopathy with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 6 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective bilateral midline posterior and lateral transforaminal decompression LUMBAR A / B, and LUMBAR X / LUMBAR Y (INCLUDES SACRAL 1 IF SELECTED) under continuous direct visualization of the spine.

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent levels to address cross-innervation. 

 

On the SELECT SIDE side the direct posterior decompression was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically at both surgical levels. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial fect joint and removal of ligamentum flavum using rongeurs and drills at both surgical levels.  The intervertebral disc and the traversing nerve root were  visualized at both surgical levels.

 

The transforaminal foraminotomy decompression was done on the same SELECT SIDE side via sequentially larger reamers were introduced into the neuroforamen with constant monitoring of the patients motor function in the lower extremity at both surgical levels.   The reaming allowed partial resection of the superior and inferior articular process  at both surgical levels.   The decompression of the neural elements was further aided by removal of the hypertrophic superior and inferior articular process using power drills.  a 3-0 Kerrison rongeur was also used during this portion of the procedure  at both surgical levels..   A continuous radiofrequency probe was used to achieve hemostasis.   At both surgical levels, an osteotome was used to perform a partial corpectomy with removal of  a section of the posterior vertebral body to surgically release the traversing and exiting nerve roots that were entrapped under the facet complex due to significant hypertrophy of the facet joints as well as the ring apophysis of the superior and inferior vertebral bodies at the surgical level.   In addition to a microdiscectomy, a partial pediculectomy was performed on the inferior pedicle of the surgical level to adequately decompress the traversing nerve root as well  at both surgical levels.  The vertebral osteotomy, and partial facet resection produced a significant increase in the neuroforaminal volume  at both surgical levels.

 

At both levels, these maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.  No additional free fragments or residual bony pathology that could further impinge spinal elements were found.

 

At the end of the case, 40 mg of Depomedrol were injected epidurally for postoperative reduction of symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  Intermil was applied as a dressing.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD

 

OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:  Back and leg pain with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Bilateral LUMBAR X / LUMBAR Y, LUMBAR  Z  facet hypertrophy, facet arthropathy, and degenerative disc disease, lateral recess stenosis due to ligamentum flavum hypertrophy, lumbar herniated disc, and upward migration of the superior articular process entrapping the exiting and traversing nerve root causing spinal stenosis claudication symptoms.

 

POSTOPERATIVE DIAGNOSIS:  Bilateral LUMBAR X / LUMBAR Y, LUMBAR  Z  facet hypertrophy, facet arthropathy, and degenerative disc disease, lateral recess stenosis due to ligamentum flavum hypertrophy, lumbar herniated disc, and upward migration of the superior articular process entrapping the exiting and traversing nerve root causing spinal stenosis claudication symptoms.

 

PROCEDURES: Bilateral midline posterior LUMBAR X / LUMBAR Y, LUMBAR  Z  laminoforaminotomy  with rhizotomy via medial and lateral branch neurectomy of the LUMBAR X / LUMBAR Y, LUMBAR  Z  facet joints with all procedures utilizing continuous radiofrequency heating each site to a minimum of 60 degrees Celsius for a minimum of 90 seconds each UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE through two separate skin and fascial incisions on both sides.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Facet arthropathy, foraminal and lateral recess stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

 

PROCEUDRES LEFT-SIDED LOCAL ANESTHESIA AND RHIZOTOMY VIA OPEN SKIN INCISION IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the LUMBAR X / LUMBAR Y, LUMBAR  Z  facet joint complex,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  LUMBAR X-1 / LUMBAR Y-1 Medial Branch and Facet Block

4.                  LUMBAR X / LUMBAR Y Medial Branch and Facet Block

5.                  LUMBAR Y, LUMBAR  Z  Medial Branch and Facet Block

6.                  Direct and continuous visualization of the LUMBAR X, LUMBAR  Y  facet joint complex with rhizotomy of the LUMBAR X, LUMBAR  Y  facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

7.                  Direct and continuous visualization of the LUMBAR Y, LUMBAR  Z  facet joint complex with rhizotomy of the LUMBAR Y, LUMBAR  Z  facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

 

PROCEDURES LEFT LATERAL RECESS DECOMPRESSION VIA SEPARATE INCISION:

1.                  Laminotomy  through separate left-sided skin and fascial incisions LUMBAR X, LUMBAR  Y  with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

2.                  Laminotomy  through separate left-sided skin and fascial incisions LUMBAR Y, LUMBAR  Z  with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

 

 

PROCEUDRES RIGHT-SIDED LOCAL ANESTHESIA AND RHIZOTOMY VIA OPEN SKIN INCISION IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the LUMBAR X / LUMBAR Y, LUMBAR  Z  facet joint complex,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  LUMBAR X-1 / LUMBAR Y-1 Medial Branch and Facet Block

4.                  LUMBAR X / LUMBAR Y Medial Branch and Facet Block

5.                  LUMBAR Y, LUMBAR  Z  Medial Branch and Facet Block

6.                  Direct and continuous visualization of the LUMBAR X, LUMBAR  Y  facet joint complex with rhizotomy of the LUMBAR X, LUMBAR  Y  facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

7.                  Direct and continuous visualization of the LUMBAR Y, LUMBAR  Z  facet joint complex with rhizotomy of the LUMBAR Y, LUMBAR  Z  facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

 

PROCEDURES RIGHT LATERAL RECESS DECOMPRESSION VIA SEPARATE INCISION:

1.                  Laminotomy  through separate left-sided skin and fascial incisions LUMBAR X, LUMBAR  Y  with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

2.                  Laminotomy  through separate left-sided skin and fascial incisions LUMBAR Y, LUMBAR  Z  with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

 

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the decompression, and rhizotomy, radiofrequency ablation procedure through separate fascial and skin incions for the laminotomy and rhizotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and posterior thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from lumbar radiculopathy and lumbar Facet Joint Dysfunction Pain Syndrome with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 12 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective bilateral LUMBAR X / LUMBAR Y, LUMBAR  Z midline posterior decompression and rhizotomy procedure under continuous direct visualization of the spine.

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors bilaterally at LUMBAR X/Y, and LUMBAR Y/Z, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed bilaterally at LUMBAR X/Y, and LUMBAR Y/Z during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent LUMBAR X-1/Y-1 level to address cross-innervation. 

 

On the RIGHT SIDE THE DIRECT POSTERIOR DECOMPRESSION was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically at both levels. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the respective laminae starting of its inferior margin and partial removal of the medial facet joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the LEFT SIDE THE DIRECT POSTERIOR DECOMPRESSION was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically at both levels. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the respective laminae starting of its inferior margin and partial removal of the medial facet joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On both sides, these maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.

 

For the RIGHT-SIDED RHIZOTOMY portion of the procedure, a tubular retractor system was placed through a  separate skin incisions at the L4, and L5 transverse process of the L4/5, and L5/S1 facet joint.  The medial and lateral branches were directly and continuously visualized, and a neurectomy was performed by dissecting and and ablating the medial and lateral branch with continuous, non-pulsed radiofrequency heating local tissues to over 60 degrees Celsius for a minimum of 90 seconds per site.

 

For the LEFT-SIDED RHIZOTOMY portion of the procedure, a tubular retractor system was placed through a  separate skin incisions at the L4, and L5 transverse process of the L4/5, and L5/S1 facet joint.  The medial and lateral branches were directly and continuously visualized, and a neurectomy was performed by dissecting and and ablating the medial and lateral branch with continuous, non-pulsed radiofrequency heating local tissues to over 60 degrees Celsius for a minimum of 90 seconds per site.

 

At the end of the case, the traversing root(s) were adequately decompressed and visualized.  There was no evidence of dural leakage.  The surgical sites were checked for hemostasis.  Forty mg of Depomedrol were injected epidurally for reduction of postoperative symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  A surgical dressing was applied.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD

 

OPERATIVE REPORT

 

PATIENT NAME:          ENTER PATIENT NAME

DOB:                            ENTER DATE OF BIRTH

 

CHIEF COMPLAINT:  Back and leg pain with decreased walking endurance and impaired functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.

 

PREOPERATIVE DIAGNOSIS:  Bilateral lumbar 5 / Sacral 1 facet hypertrophy, facet arthropathy, symptomatic painful sacroiliac joint syndrome, and degenerative disc disease, lateral recess stenosis due to ligamentum flavum hypertrophy, lumbar herniated disc, and upward migration of the superior articular process entrapping the exiting and traversing nerve root causing spinal stenosis claudication symptoms.

 

POSTOPERATIVE DIAGNOSIS:  Bilateral lumbar 5 / Sacral 1 facet hypertrophy, facet arthropathy, symptomatic painful sacroiliac joint syndrome, and degenerative disc disease, lateral recess stenosis due to ligamentum flavum hypertrophy, lumbar herniated disc, and upward migration of the superior articular process entrapping the exiting and traversing nerve root causing spinal stenosis claudication symptoms.

 

PROCEDURES: Bilateral midline posterior Lumbar 5 / Sacral 1 laminoforaminotomy  with rhizotomy via medial and lateral branch neurectomy of the Lumbar 5 / Sacral 1 facet joint, bilateral sacroiliac ablation with both procedures utilizing continuous radiofrequency heating each site to a minimum of 60 degrees Celsius for a minimum of 90 seconds each UNDER CONTINUOUS DIRECT VISUALIZATION OF THE SPINE through two separate skin and fascial incisions on both sides.

 

FLUOROSCOPY:                       < 1 hour

 

PROCEDURE LOCATION:         SELECT FACILITY

 

ATTENDING PHYSICIAN:          SELECT SURGEON, MD

 

ASSISTANT:                              SELECT ASSISTANT, RNFA

 

ANESTHSIA:                             SELECT ANESETHESIA

 

ANESTHESIOLOGIST:               SELECT DR. ANESETHESIOLOGIST

 

COMLICATIONS:                     SELECT NONE, BLEEDING, DUROTOMY, FREE TEXT

 

NEUROLOGIC MONITORING: Direct intraoperative nerve stimulation (electrical and tactile).

 

FINDINGS:                                Facet arthropathy, foraminal and lateral recess stenosis due to hypertrophied ligamentum flavum, facet hypertrophy, degenerative disc disease with herniated nucleus pulposus

 

MEDICATIONS:

1.      SELECT ANTIBIOTIC (ANCEF 1G, ANCEF 2G, ANCEF 3G, VACOMYCIN 1G, 600 MG CLINDAMYCIN, 900MG CLINDAYMYCIN) given within 20 minutes of making an incision

2.      Decadron 10 mg i.v. given within 20 minutes of making an incision

3.      Less than 30 cc of 0.25% bupiviciane with epinephrine local anesthesia, 40 mg depomedrol epidurally given by surgeon.

 

 

PROCEUDRES LEFT-SIDED LOCAL ANESTHESIA AND RHIZOTOMY VIA OPEN SKIN INCISION IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the L4/5, and L5/S1 facet joint complex,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  L4/5 Medial Branch Block

4.                  L5/S1 Medial Branch Block

5.                  Direct and continuous visualization of the L5/S1  facet joint complex with rhizotomy of the L5/S1 facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

 

PROCEDURES LEFT LATERAL RECESS DECOMPRESSION VIA SEPARATE INCISION:

1.                  Laminotomy  through separate left-sided skin and fascial incisions L5/S1 with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the left side decompressing the traversing nerve root under the direct and continuous visualization.

 

PROCEDURES LEFT SI-JOINT ABLATION VIA SEPARATE INCISION:

1.                  Radiofrequency ablation of the left-sided SI-Joint with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side under direct and continuous visualization through separate skin and fascial incision.

 

PROCEUDRES RIGHT-SIDED LOCAL ANESTHESIA AND RHIZOTOMY VIA OPEN SKIN INCISION IN DETAIL:

1.                  Local skin anesthesia in a trajectory aiming for the L4/5, and L5/S1 facet joint complex,

2.                  Local anesthesia at the high spot of the iliac crest on the surgical side,

3.                  L4/5 Medial Branch Block

4.                  L5/S1 Medial Branch Block

5.                  Direct and continuous visualization of the L5/S1  facet joint complex with rhizotomy of the L5/S1 facet joint complex via neurectomy of the directly visualized medial and lateral branch with controlled neural dissection and ablation with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side.

 

PROCEDURES RIGHT LATERAL RECESS DECOMPRESSION VIA SEPARATE INCISION:

1.                  Laminotomy  through separate right-sided skin and fascial incisions L5/S1 with partial removal of the inferior lamina via laminotomy with additional removal of ligamentum flavum on the right side decompressing the traversing nerve root under the direct and continuous visualization.

 

PROCEDURES RIGHT SI-JOINT ABLATION VIA SEPARATE INCISION:

1.                  Radiofrequency ablation of the right-sided SI-Joint with continuous, non-pulsed radiofrequency application heating tissues to over 60 degrees Celsius for a minimum of 90 seconds per ablation site on this surgical side under direct and continuous visualization through separate skin and fascial incision.

 

 

INDICATION FOR PROCEDURE:

 

The patient has failed non-operative multimodality treatments for the preoperative condition and therefore consented to the decompression, rhizotomy, and SI-Joint radiofrequency ablation procedure through separate fascial and skin incions for the laminotomy and rhizotomy part of the procedure. 

 

The patient tells me that there have been multiple acute onset of excruciating disabling pain of an otherwise chronic disease course over a longer period of time.  The patient is in pain practically every day and has described the pain as aching, cramping, fearful, gnawing, heavy, hot or burning, sharp, shooting, at times sickening, splitting, stabbing, and often as punishing or cruel, throbbing, and most of the time as tiring and exhausting.

 

The patient’s lumbar symptoms including numbness, tingling and weakness radiating down from the low back and into the buttocks and posterior thigh and calf into the toes are easily triggered with any activity but particularly by prolonged standing, carrying a heavy, weight, prolonged forward flexion.  The patient is only able to get slow partial relief of symptoms with rest by sitting or lying down.

 

The patient describes a significant Limitation of Activities of Daily Living (ADLs) including bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, handwriting and typing, housework, doing laundry, driving, and managing finances. In addition, there are some concerning patient safety issues with the patient’s mobility and control of motor function, which produces a higher fall risk.

 

The patient has had an extensive trail of non-operative measures including physical therapy, chiropractic care, manipulation, self-directed exercise programs, acupuncture, biofeedback, and activity modification, weight loss, and unsuccessful trail of medical management with pain medication including NSAIDs and narcotics.   In addition, the patient has had contraindications to non-surgical management including intolerance to NSAIDs affecting the patient’s liver, kidney and heart function.  Moreover, the patient had to make use of assistive devices.

 

The patient suffers from lumbar radiculopathy and SI Joint Dysfunction Pain Syndrome with sensory deficits and pain and pain induced weakness.  According to Evidence Based Consensus Treatment Guidelines for Multidisciplinary Spine Care recognized and published by a number of national organizations and health insurance carriers, and the 2016 InterQual Medical necessity criteria for surgical procedures the patient’s lumbar discectomy, foraminotomy, and/or laminotomy is medically necessary because the patient has unremitting lumbar radiculopathy and progressive weakness secondary to nerve root compression in setting of failed non-operative treatment including PT and NSAIDs for the required minimum time period of 12 weeks.

 

The summary description of the patient’s physical examination shows decreased functioning in the context of the patient’s Activities of Daily Living due to disabling pain with decreased mobility, and decreased range of motion, deformity, crepitus and tenderness of the affected spinal motion segments.  Therefore, surgically treatment of the patient’s condition is appropriate and medically necessary.

 

I discussed the procedure in detail, expected outcomes and benefits which includes a reduction of the patient's symptoms rather than complete resolution. Potential risks of the surgery were discussed with the patient  which include but are not limited to blood loss, nerve, and vessel damage, paralysis, paraplegia, death, infection, dural leakage, foot drop, upper and lower extremity weakness, change in bladder and bowel function, bowel perforation, dysethetic leg pain, development of blood clots causing pulmonary embolism, use of non-FDA approved devices, failure of pain relieve, need for more spinal surgery including spinal fusion surgery.  The patient had a chance to ask questions, all of which were answered to the patient's satisfaction.  Informed consent was obtained in the office.

 

NARRATIVE DESCRIPTION OF THE PROCEDURE:

The risks and benefits and alternative treatments have been thoroughly reviewed in clinic prior to today and the patient has reviewed the Center for Advanced Spinal Care patient education materials on this procedure. The patient has signed the informed consent for the direct posterior midline and paraspinal transforaminal decompression as outlined above.  The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitors were applied, and the back was prepped with CHG and Chloraprep, and draped in a standard sterile surgical fashion.  The fluorscopy unit was sterilely draped and brought into the field for intraoperarive imaging and identification of surgical level.   Prior to making an incision a time-out was performed identifying the patient as ENTER PATIENT NAME who came to the OR for an elective bilateral L5/S1 midline posterior decompression rhizotomy and SI Joint ablation under continuous direct visualization of the spine.

 

After local skin anesethesia was applied, small open incisions were made over the surgical level and the spine was accessed with the aid surgical tubular retractors bilaterally at L5/S1, whose position was then radiographically verified intraoperatively.  Facet and medial branch blocks were also performed bilaterally at L5/S1 during this portion of the case to achieve intra- and postoperative pain control.  These procedures were also done at adjacent L4/5 level to address cross-innervation. 

 

On the RIGHT SIDE THE DIRECT POSTERIOR DECOMPRESSION was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically. An endoscope was also used during this portion of the case to aid in the continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial facet joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On the LEFT SIDE THE DIRECT POSTERIOR DECOMPRESSION was done via a hemilaminotomy was performed and the lateral recess was decompressed surgically in a similar manner under continuous direct visualization of the the surgery.  This resulted in partial removal of the lamina starting of the inferior margin and partial removal of the medial facet joint and removal of ligamentum flavum using rongeurs and drills.  The intervertebral disc and the traversing nerve root were  visualized.

 

On both sides, these maneuvers allowed adequate visualization of the herniated disc and several large fragments were removed from the intervertebral disc thereby decompressing the axilla between the exiting and traversing nerve root and below the dural sack centrallly.  This allowed inspection of the anterior spinal canal and of the decompressed lateral recess.

 

For the RIGHT-SIDED RHIZOTOMY portion of the procedure, a tubular retractor system was placed through a  separate skin incisions at the L5 transverse process of the L5/S1 facet joint.  The medial and lateral branch were directly and continuously visualized, and a neurectomy was performed by dissecting and and ablating the medial and lateral branch with continuous, non-pulsed radiofrequency heating local tissues to over 60 degrees Celsius for a minimum of 90 seconds per site.

 

The RIGHT-SIDED SI ABLATION was done through a separate skin and fascial incision in a similar manner under direct and continuous visualization with mechanical debridement and ablation with radiofrequency in the same manner as for the rhizotomy.

 

For the LEFT-SIDED RHIZOTOMY portion of the procedure, a tubular retractor system was placed through a  separate skin incisions at the L5 transverse process of the L5/S1 facet joint.  The medial and lateral branch were directly and continuously visualized, and a neurectomy was performed by dissecting and and ablating the medial and lateral branch with continuous, non-pulsed radiofrequency heating local tissues to over 60 degrees Celsius for a minimum of 90 seconds per site.

 

The LEFT-SIDED SI ABLATION was done through a separate skin and fascial incision in a similar manner under direct and continuous visualization with mechanical debridement and ablation with radiofrequency in the same manner as for the rhizotomy.

 

At the end of the case, the traversing root(s) were adequately decompressed and visualized.  There was no evidence of dural leakage.  The surgical sites were checked for hemostasis.  Forty mg of Depomedrol were injected epidurally for reduction of postoperative symptoms.  The wound was closed with a horizontal matress stich using 4-0 monocryl.  A surgical dressing was applied.

 

 

FOLLOW-UP:

The patient was observed to be without any new neurologic signs or symptoms, transported to the recovery area, and discharged with standard written and verbal home going instructions.

 

The patient is to see me in the office within 2 weeks.  A follow up appointment has been scheduled for the patient.  The patient did received prescriptions for postoperative pain medication in the office prior to surgery.  The patient also received informational material on the use of the discharge medication and signed an educational consent form for the proper use of these medications. 

 

The patient was instructed to call my office with persistent fevers, chills, drainage from the wound, or increasing back or leg pain.  The patient knows how to reach me by calling my office at 520-204-1495.

 

Kai-Uwe Lewandrowski, MD