PREOPERATIVE DIAGNOSIS: Uncontrolled epilepsy.

POSTOPERATIVE DIAGNOSIS: Uncontrolled epilepsy.

PROCEDURE PERFORMED: Left vagal nerve stimulator insertion.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Less than 10 mL.

COMPLICATIONS: None.

DRAINS: None.

OPERATIVE FINDINGS: A model 102 generator with 2 mm electrodes was utilized.

INDICATION FOR PROCEDURE: The patient is a (XX)-year-old child who was found to have progressive epilepsy. It was recommended that a vagal nerve stimulator be placed. We discussed the options, the risks and benefits with the child’s parents, and their questions were welcomed and answered. The procedure and potential risks of surgery include, but are not limited to, vagal nerve injury, vascular damage, stroke, inoperability, malfunction, the need for continuous monitoring and evaluations, the possible need for further surgical interventions, among others. With the family’s understanding and permission, the child was brought to the operating room for this procedure.

DESCRIPTION OF PROCEDURE: After suitable general endotracheal anesthesia was obtained, the patient was placed in the supine position and the head immobilized in a donut. The skin was prepared using Betadine scrub and solution and a suitable surgical drape. Marcaine with epinephrine was infiltrated.

Initially, we made a 2.5 cm incision along the neck crease, and the platysma muscle was divided. The sternocleidomastoid muscle was retracted and dissected medially, and we identified the carotid sheath. The carotid sheath was opened and we identified the vagal nerve. This was then isolated with vessel loops.

We then attached the two electrodes in the grounding mechanism using 2 mm size coils. These were found to be securely placed and a small loop was left for anchoring.

We then prepared the pocket while making a 6 cm curvilinear incision just medial to the axilla. A subcutaneous pocket was created over the pectoralis muscle, and the area was irrigated.

We then used the tunneling device from the cervical to the chest incisions, and the electrodes were placed in the subcutaneous tunnel. The model 102 generator was then connected to the electrodes. An impedance test was done and was found to be 1.

The electrode in the subclavian was left with a small loop for growth, and this was anchored to the fascia using a Vicryl suture.

Subsequently, the generator was turned on at the 0.25 mA at 30 Hz, on 30 seconds, off for 5 minutes, with a magnet strength of 0.5 for 60 seconds.

The wounds were then irrigated and subsequently painted with Betadine solution. They were then closed using 3-0 Vicryl sutures for the deep layer. The skin was approximated using 4-0 Vicryl suture in a running subcuticular fashion. Steri-Strips were applied, and the patient was awakened and transported to the recovery room, having tolerated the procedure well.

We discussed the operation, the findings, the potential implications and complications with the patient’s family. Their questions were welcomed and answered, and they expressed understanding of the situation.

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PREOPERATIVE DIAGNOSIS:  Left ruptured fusiform internal carotid artery aneurysm.

POSTOPERATIVE DIAGNOSIS:  Left ruptured fusiform internal carotid artery aneurysm.

OPERATIONS PERFORMED:
1.  Left external carotid artery-MCA bypass with saphenous vein.
2.  Opening of the carotid artery of the neck, internal and external.
3.  Frontotemporal craniotomy.
4.  Trapping of the aneurysm.

SURGEON:  John Doe, MD

ASSISTANTS:
1.  Jane Doe, MD
2.  John Roe, MD

COMPLICATIONS:  None.

SPECIMEN:  None.

DESCRIPTION OF OPERATION:  The patient was intubated and placed in the supine position with the head tilted to the left. The neck and the frontotemporal area was prepped and draped in sterile fashion. The first incision was made at the level of the neck with a 15 blade, and the incision was carried down with Bovie coagulator. The platysma was incised and was opened. The carotid artery was first found at the level of the common carotid artery and followed up to the bifurcation, where the facial vein was ligated and divided. Then, the internal and external carotids were identified. Vessel loops were passed around both arteries, and the external carotid was prepared for approximately 5 cm for possible bypass.

The frontotemporal craniotomy was then performed using first a 10 blade scalpel and Bovie coagulators in the scalp, and the temporalis muscles were reflected anteriorly and inferiorly. With the Midas-Rex, craniotomy was performed, and the dura was opened in a C-shaped fashion.

Under the microscope for microdissection and illumination, the sylvian fissure was widely opened from distal to proximal with this portion of the entire MCA areas, including the internal carotid artery and also the aneurysm. At this point, after the saphenous vein was harvested by Dr. Jane Roe and her vascular group, the saphenous vein was passed under the skin and then the proximal anastomosis was performed at the level of the external carotid, which was cross clamped. The anastomosis was performed with interrupted 8-0 Prolene. After DeBakey clamps were removed, there was great flow, and the anastomosis was then performed at the level of the MCA, and we selected the temporal branch of the MCA because it was the largest and the healthiest. Two temporary clips were applied and the anastomosis then performed with interrupted 10-0 Prolene. After that, the clips were removed and the anastomosis appeared to work perfectly.

At this point, a cerebral angiogram was obtained, which showed that at the clamping of the internal carotid artery of the neck, the entire left hemisphere was supplied by the bypass, and the vascular ejection time was within normal range. EEG and somatosensory-evoked potentials also never changed after the occlusion of the internal carotid artery and bypass completion.

At this point, we went back under the microscope and isolated the aneurysm and shot through the aneurysm with three straight 11 mm clips. Another angiogram was again performed, which showed the internal choroidal artery was preserved.

At this point, the dura was closed with 4-0 Vicryl. The bone flap was replaced and partially trimmed to leave the bypass flowing normally and fixed with mini-plates. The muscle was also loosely attached with 2-0 Vicryl. The subcutaneous tissue was closed with 3-0 Vicryl and the skin closed with staples. A Jackson-Pratt was left in the subgaleal space. The neck incision was closed with 2-0 Vicryl, 3-0 Vicryl and subcuticular for the skin.

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PREOPERATIVE DIAGNOSIS:  Right clinoidal meningioma.

POSTOPERATIVE DIAGNOSIS:  Right clinoidal meningioma.

OPERATION PERFORMED:
1.  Orbital frontal approach with complete anterior clinoidectomy.
2.  Gross total resection of clinoidal meningioma.
3.  Microdissection using operating room microscope.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old woman who presented to the emergency room with grand mal seizure. Imaging workup of the brain showed evidence of an enhancing mass stemming from the anterior clinoid process consistent with a clinoidal meningioma. There was significant amount of brain shift and surrounding brain edema, and therefore, it was recommended that the tumor be removed as the best means of treatment.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed under general anesthesia. She was then placed supine on the operating room table. Mayfield headrest was applied to the skull, and she was positioned in preparation for a pterional-type orbital frontal craniotomy. The neck was maintained in neutral position so that the jugular veins would drain freely. The right frontotemporal area was then prepped and draped in the usual sterile fashion.

Using a #15 blade knife, the skin was incised along the course of the planned pterional-type craniotomy. The scalp was reflected inferiorly and held in place with suture. The temporalis muscle was incised leaving a mild fascial cuff for later reattachment and also retracted inferiorly.

A Midas Rex drill was then used to create entry bur holes at the orbital frontal angle and in the temporal area. The Midas Rex drill was then used to create an orbital frontal-type craniotomy taking with the pterional bone flap of the orbital roof. This was a one piece-type orbital frontal craniotomy. Small tear in the orbital periosteum was repaired with 4-0 Nurolon suture.

Temporal and frontal lobe retractors were then placed and extradural complete anterior clinoidectomy was performed using microsurgical technique and the operating room microscope. An AMA drill bit was used to microsurgically bur down the hypertrophic anterior clinoid after releasing from surrounding tumor-involved dura. Once the anterior clinoid was removed and the tumor undermined and released from the bony attachment, the dura was opened in a curvilinear fashion and retracted anteriorly.

Frontal and temporal retractors were again placed carefully on the brain underneath. The basal cistern was opened to allow CSF to drain and relax the brain. The tumor was then circumscribed first releasing it from the sterile attachment and devascularizing it completely. The dural base of the tumor was also excised. Bipolar cautery and gentle blunt dissection was used to develop the arachnoid and peel plain between the tumor dome and the surrounding brain tissue.

The tumor was circumscribed completely and removed in nonblocked fashion achieving a gross total resection. Hemostasis was obtained with bipolar cautery. The wound was irrigated with warm saline solution to confirm hemostasis. The dura was then reapproximated using interrupted 4-0 Nurolon sutures. Central dural tack-up suture was placed and the bone was secured with Synthes titanium plates and mini screws.

A subgaleal JP drain was placed, and the galea was reapproximated using interrupted 0 Vicryl sutures. Staples were then placed to reapproximate the skin edges. Sterile dressing was placed. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

It should be noted that a small separate permanent section was sent from the dura along its incision line. A small mass was found here and had the appearance of a separate small meningioma measuring less than 4 mm in diameter. The specimen was labeled superficial tumor.

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PREOPERATIVE DIAGNOSIS: Chiari I malformation with cervical syrinx.

POSTOPERATIVE DIAGNOSIS: Chiari I malformation with cervical syrinx.

OPERATION PERFORMED:
1. Suboccipital craniectomy.
2. C1 laminectomy.
3. Duraplasty.

SURGEON: John Doe, MD

ANESTHESIA: General

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old woman who presents with neck pain, progressive early signs of myelopathy, on imaging demonstrates cervical syrinx from C1 through T1, Chiari I malformation, cerebellar tonsils descending to the superior arch of C2 level. Indication, risks, and details for craniectomy with duraplasty has been explained to the patient. The patient requested to proceed with surgery.

OPERATIVE FINDINGS: Cerebellar tonsillar compression at the C1 ring level associated with fibrosis and thickening of the dura and dilation of the upper cervical cord consistent with the underlying syrinx.

DESCRIPTION OF OPERATION: The patient was taken to the operating room and underwent general anesthetic. She was given a gram of Ancef preoperatively, placed in the Mayfield headrest, rolled prone on chest rolls where her neck was kept in a neutral position. Posterior occipital cervical region was shaved, prepped, and draped out sterilely.

A midline incision was made reflecting the tissue away from the suboccipital bone, exposing C1 and C2. The occipital bone appeared to be somewhat flattened consistent with the underlying Chiari malformation. The bone was thinned out with a high-speed drill and decompressed completing a craniectomy in the suboccipital bone in an oval fashion, up to but not including the region of the transverse sinus. C1 arch was removed posteriorly as well. The midline dura was quite thickened at the level of the craniocervical junction. This tissue was sharply excised and then a midline opening in the dura made, extending from the superior portion of C2 up just to the right of the midline and then across the midline decompressing the cerebellar tonsils. They were noted to be somewhat scarred and very adherent to the underlying cervical cord at the C1 level. There was dilation of the cervical cord consistent with the underlying syrinx and significant flattening of the cerebellar tonsils. Using microdissection, the tonsils were freed up from the underlying cervical cord. A small amount of cautery used to shrink up the fibrotic portion of the tonsils and to allow for opening up of the entrance into the fourth ventricle.

Following wide decompression, duraplasty was performed using a piece of ligamentum nuchae harvested during exposure. This was reapproximated in a watertight fashion with 4-0 Prolene in a running fashion. DuraGen and Gelfoam were placed over the exposure. The wound was closed in layers with Vicryl suture, 3-0 nylon for skin, and a dry dressing applied. The patient was rolled supine, extubated, and taken to the recovery room in stable condition. Sponge and needle counts were correct. Estimated blood loss was approximately 100 mL.

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PREOPERATIVE DIAGNOSES:
1.  Neurogenic claudication.
2.  Spinal stenosis, L4-5.

POSTOPERATIVE DIAGNOSES:
1.  Neurogenic claudication.
2.  Spinal stenosis, L4-5.

OPERATION PERFORMED:  Lumbar decompression with decompressive partial laminectomy and foraminotomy, L4-5.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

BLOOD LOSS:  Less than 25 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  After informed consent, the patient was taken to the operating room, and general anesthesia was induced. He was then placed prone on a Wilson frame. The pressure points and extremities were padded in the routine fashion. He was given routine preoperative prophylactic antibiotics and a time-out identified the operative site. The spine was then prepped and draped in the standard sterile fashion.

We made an incision from the L4 to the L5 spinous process. The incision was carried through the skin with a knife. We then used Bovie cautery to dissect down to the fascia. The fascia was then divided, and the paraspinal musculature was elevated out of the L4-L5 lamina out of the L4-5 facet, which was preserved. We then confirmed position with C-arm fluoroscopy. We then took down the spinous ligament at L4-5 and took down the cephalad portion of the L5 spinous process in the caudal region of the L4 spinous process. We then continued to work on the ligamentum flavum. There was tremendous hypertrophy of the ligamentum flavum, took significant amount of time to actually enter the spinal canal. Once we entered the spinal canal, again we were able to work on this significantly redundant ligamentum flavum. We used the bur to extend our partial laminotomy on the caudal portion of L4. We also took out a small portion of cephalad portion of L5. We were able to then continue to clear out the ligamentum flavum and bone out to the lateral recess. The lateral recess at L4-5 was then addressed using Kerrison protecting the dural sac with Woodson elevator and cotton padding. We then were able to also clear out the L4-5 foramen again using protection with Woodson elevator and cotton padding. Similarly, we were able to make sure that the dural sac had enough room for the transiting L5 nerve root. Following this, we felt like he had an adequate decompression. We could easily pass a Murphy ball probe out through the neural foramen and also under the L4 and L5 lamina without difficulty. We then copiously irrigated the incision. We had the anesthesiologist perform a Valsalva. There was subsequently no evidence whatsoever of a dural leak.

We then closed the fascia using 0 Vicryl in figure-of-eight fashion. We again copiously irrigated, closing the subcutaneous tissue with 2-0 followed by 3-0 Vicryl in interrupted fashion and a 4-0 Monocryl running subcuticular for the skin. Marcaine 0.5% was injected for analgesia. The sponge and needle counts were correct x2. The patient tolerated this procedure well and was taken to recovery in stable condition.

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PREOPERATIVE DIAGNOSIS:  Hydrocephalus.

POSTOPERATIVE DIAGNOSIS:  Hydrocephalus.

OPERATION PERFORMED:  Ventriculoperitoneal shunt.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

COMPLICATIONS:  None.

SPECIMENS:  None.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old gentleman who has a history of a severe subarachnoid, intraventricular hemorrhage, who was treated and had a great recovery. The ventriculostomy, however, has not been able to be removed, and so before sending the patient to rehab, the decision was made to proceed with ventriculoperitoneal catheter. The patient understands the risks and benefits of the procedure and particularly the risks, which mainly consist of stroke, hematoma, reoperation and infection and signed the consent.

DESCRIPTION OF OPERATION:  The patient was intubated and placed in a supine position with his head slightly tilted to the right. The previous left frontal incision, where the previous ventricular catheter was placed, was prepped along with the posterior parietal area, the left side of the neck, and the abdomen. These areas were then draped in a sterile fashion.

First, an incision was made at the level of the frontal area where a bur hole was made with the Midas-Rex. Then, the peritoneal catheter was passed from the frontal area to the posterior parietal area and then to the right abdominal area. The peritoneal catheter was then connected to a programmable valve set at 120 mm of water. After that, the dura was opened and then a ventricular catheter was inserted into the ventricle at a depth of 6 cm. Then, the ventricular catheter was connected to the programmable valve after verification of flow. After all connections were made, the peritoneal catheter was checked for spinal fluid flow. Then, the abdominal wall was dissected in layers, and the peritoneal cavity was opened and the peritoneal catheter was inserted into the peritoneal cavity.

Then, all the incisions were irrigated with antibiotic solution. The frontal incision was closed with 3-0 Vicryl and 3-0 nylon. The small posterior parietal incision was closed with staples and the abdominal wall incision was closed with 2-0 Vicryl, 3-0 Vicryl and Dermabond for the skin.

Sample #2

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hydrocephalus.

POSTOPERATIVE DIAGNOSIS:  Hydrocephalus.

OPERATION PERFORMED:  Right frontal ventriculoperitoneal shunt insertion.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General with endotracheal intubation.

ESTIMATED BLOOD LOSS:  Less than 25 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room where she was induced under general anesthesia and intubated. She was placed in the supine position with the head turned slightly to the left, resting on a donut headrest. The site around the previous ventriculostomy was shaved, prepped, and draped in the usual sterile fashion extending down over the neck and chest to the right upper quadrant of the abdomen.

A curvilinear incision was made around the planned bur hole site in the scalp with #10 blade and Bovie electrocautery. The flap was held open with self-retaining retractor. Particular attention was paid to leaving periosteal tissue on the bone for tack-down sutures. The previous ventriculostomy catheter was identified and left in place. In the abdomen, a linear incision was made three fingerbreadths below the right costal margin with a #10 blade. Bovie electrocautery was used to divide the subdermal fat and the fascia. The muscle fibers were split, and the deep fascia was opened with Church scissors. The peritoneum was alternately grasped and released, ensuring no bowel entrapment and then opened with the Church scissors.

Intraperitoneal exposure was confirmed by placement of a Penfield 4 dissector without resistance. A pursestring suture with 3-0 silk was placed around the peritoneal opening. The tunneling catheter was then passed under the subcutaneous tissues from the abdomen up to the neck where a jump incision was made. The shunt tunneler was irrigated with antibiotic irrigation. The distal catheter was passed through from this location and the tunneler removed. A new tunneler was then passed from the scalp to the jump incision of the neck and the distal tubing was then passed all the way up to the scalp incision in this manner. The programmable valve and the distal tubing were both primed with lactated Ringer’s and then attached, being secured with a 3-0 silk tie.

At this point, the ventriculostomy catheter was removed. A new ventricular catheter was then passed through the previous tract without a stylet with CSF coming out under pressure at a depth of 5 cm from the outer table. It was secured at 6 cm from the outer table and cut to length. It was attached to the proximal end of the valve and secured with the 3-0 silk tie. The distal tubing was pulled from the abdomen as the valve was then tunneled under the scalp away from the incision. Normal spontaneous antegrade flow was confirmed at the distal tip of the catheter. At this point, the distal catheter was cut to length and placed into the peritoneum. The pursestring was then secured. The ventricular catheter was secured to the periosteum over an elbow connector with a 3-0 silk stitch.

The galea was then closed with 2-0 Vicryl sutures and the skin closed with skin staples. The abdominal wound was closed with 3-0 Vicryl sutures in the deep fascia and in the subdermal layer, followed by a 4-0 running Monocryl stitch in the skin. Both wounds were then dressed with a Telfa dressing, sponge, and paper tape. The patient was then awakened from anesthesia and extubated without difficulty. The patient was taken to the PACU in stable condition.

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PREOPERATIVE DIAGNOSIS:  Coccydynia.

POSTOPERATIVE DIAGNOSIS:  Coccydynia.

OPERATION PERFORMED:  Coccygectomy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old man with a long history of coccydynia. The cause of his coccydynia remains idiopathic. The patient’s pain progressed and ultimately required narcotic analgesics for management. He became habituated to the narcotics, they became ineffective, and a Dilaudid pump was placed to help minimize the systemic effects of oral analgesics. The pump was not effective in relieving his coccygeal pain, and he subsequently developed idiopathic flexion deformity of his cervical spine. Despite having a significant cervical flexion deformity, his primary complaint remained coccydynia. The patient elected to go ahead with coccygectomy. The patient’s physical exam certainly supported a coccydynia and dysmorphic coccyx. It was very tender to palpation and appeared to be broken. A CT scan was performed of the lower coccygeal segment, and this showed evidence of a 90-degree angular deformity of the terminal coccyx. Understanding the risks and benefits of the surgery, the patient elected to proceed with coccygectomy in hopes that this might relieve his long-standing coccygeal pain.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Wilson frame. All bony prominences were inspected and padded prior to sterile draping. The sacrococcygeal area was then prepped and draped in the usual sterile fashion.

Using a #15 blade knife, the skin was incised in the midline over the terminal coccygeal segment. Monopolar cautery was then used to expose the terminal coccygeal segment. The coccygeal segment was released from soft tissue attachments using monopolar cautery and removed. It was clearly dislocated from the intact sacral segment. A Leksell rongeur was then used to contour the terminal sacral segment to prevent it from being prominent.

The wound was copiously irrigated with antibiotic solution. The terminal coccygeal segment itself was sent for pathology. The fascia was then reapproximated using interrupted 0-Vicryl sutures, and interrupted 3-0 Vicryl sutures were used to reapproximate the subcuticular layer. A sterile Dermabond dressing was then placed. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

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PREOPERATIVE DIAGNOSIS:  Right frontal brain tumor.

POSTOPERATIVE DIAGNOSIS:  Right frontal brain tumor.

OPERATION PERFORMED:  Right frontoparietal craniotomy with image-guidance system and removal of the tumor.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

COMPLICATIONS:  None.

SPECIMEN:  Brain tumor.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old gentleman who was sent into the emergency room with new-onset seizures. In the ER, we evaluated with CT scan and MRI, which showed the presence of a right frontal lesion consistent with brain tumor. After evaluation and discussion with the family and the patient, we decided to schedule surgery, which will consist of removal of the brain tumor. Prior to surgery, the patient had an MRI scan, BrainLab image-guidance system. The patient and the family understood the situation and understood the findings and the risks and benefits of the procedure. In particular, the risk of surgery is mainly, but not exclusively, stroke, hematoma, reoperation, infection, seizures, CSF leak, meningitis or paralysis. The patient did understand all the risks, the family understood the risks, questions were also answered, and the patient finally consented.

DESCRIPTION OF OPERATION:  The patient was intubated and placed in the supine position with the head in the Mayfield head holder. The image-guidance system was brought to the OR, and the patient’s head was registered to the BrainLab system. After that, the ideal craniotomy area was mapped on the scalp and localization of the tumor was then completed.

A linear incision was then marked on the scalp. It was prepped and draped in the usual sterile fashion. An incision was made with a 10 blade scalpel, and Bovie coagulator and the scalp was reflected anteriorly and inferiorly. Then, with the use of Midas-Rex, a craniotomy was performed anterior to the coronal suture, approximately 4 cm, and stenting posteriorly to the coronal sutures approximately 3 cm. This allowed us to completely control the entire tumor mass. After that, the craniotomy was performed and mid dura was opened with the base to the superior sagittal sinus. By using the image guidance, the tumor margins were mapped on the brain and then the resection was started by opening the arachnoid on the surface in the way to completely outline the superficial part of the tumor. Then, the resection was gradually completed by debriding all the directions with the help of the image guidance to make sure that we were all the way around the tumor. The biopsy was sent to pathology and the answer is that this is brain tumor, but the type is still not clear at the frozen section.

Hemostasis was accomplished. The dura was closed with 4-0 Nurolon in a watertight fashion. DuraGen was applied over the dura, the bone flap was replaced and secured with miniplate, and the Jackson-Pratt was left in the subgaleal space. The scalp was closed with 2-0 Vicryl and staples for the skin.

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PREOPERATIVE DIAGNOSIS:  Left cerebellar brain tumor.

POSTOPERATIVE DIAGNOSIS:  Left cerebellar brain tumor.

OPERATIONS PERFORMED:
1.  Posterior fossa craniotomy.
2.  Gross total excision of metastatic cerebellar brain tumor.
3.  Microdissection using operating room microscope.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old man who complained of gradually increasing lethargy and unsteadiness on his feet. He came to the emergency room and had a CT scan of his brain performed. This showed evidence of a large 4.5 cm mass occupying most of the left cerebellar hemisphere and causing occlusion of the fourth ventricular pathway. Because of the occlusion of the fourth ventricular pathway and evidence of early hydrocephalus on the scan, it was recommended that he be taken to the operating room on an emergent basis for evacuation of the mass. A chest x-ray showed a large middle lobe mass measuring 9.5 cm in diameter consistent with a lung primary. It was suspected that the left cerebellar mass represented a metastatic deposit from his lung tumor.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed under general anesthesia. He was then placed in a Mayfield headrest and positioned prone on gel rolls. His neck was maintained in gentle flexion in a neutral rotation. The posterior cervical area was then prepped and draped in the usual sterile fashion.

Using a #15 blade knife, the skin was incised in the midline, and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect the paraspinal muscles and occipital galea laterally exposing the occipital bone and the C1 and C2 vertebrae. In order to gain access to the foramen magnum and low cerebellar area, a decompressive C1 and C2 laminectomy was performed. This provided a better view to the patient’s steep occipital bone. A Leksell rongeur was used to perform the bilateral laminectomy of C1 and C2. The Midas Rex drill was then used to create entry bur holes on either side of the midline of the occipital bone just below the transverse sinus. The Midas Rex drill was then used to turn an occipital flap crossing the midline and centered more to the left than the right. The flap was removed exposing the underlying dura. The dura was opened in a curvilinear fashion exposing the left cerebellar hemisphere and the foramen magnum. CSF was withdrawn decompressing the posterior fossa.

Corticectomy was then performed exposing the tumor. The operating room microscope was brought into the field and used to assist with performing a microsurgical removal of the tumor. Bipolar cautery was used to develop a plane between the tumor and the surrounding normal cerebellar tissue. Hemostasis was obtained using the same technique. Excellent resection was achieved. Specimen was sent for permanent section. The tumor was soft and friable.

Following gross total resection and establishment of hemostasis, the dura was then reapproximated using interrupted 4-0 Nurolon sutures. The repair was reinforced with 5 mL of Tisseel. Gelfoam was then placed over the repair. The bone flap was replaced and screwed and secured with Synthes miniplates and screws. The wound was then irrigated with antibiotic solution and closed in the usual fashion using interrupted 0 Vicryl sutures on the fascia and interrupted 2-0 sutures on the subcuticular layer followed by staples on the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

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PREOPERATIVE DIAGNOSIS:  Unstable L2 burst fracture.

POSTOPERATIVE DIAGNOSIS:  Unstable L2 burst fracture.

OPERATION PERFORMED:
1.  Posterior lumbar open reduction of L2 fracture.
2.  Placement of Synthes Schanz type screws and rods from L1 through L3 nonsegmentally.
3.  Posterolateral facet arthrodesis from L1 through L3 using locally harvested morcellized corticocancellous autograft bone and BMP.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old man who was involved in an accident. He was underneath a scaffolding. The scaffolding apparently broke loose falling on top of him. The patient complained of the immediate onset of back pain but denied any numbness or weakness in his lower extremities. He was brought to the emergency room for further workup. Imaging showed evidence of an L2 burst fracture with fracture of the posterior elements. The fracture was deemed to be unstable, and it was recommended that surgery be done to realign the fracture and to reduce his kyphotic deformity.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed under general anesthesia. He was then placed prone on a Jackson table. All bony prominences were inspected and padded prior to sterile draping.

Using a #15 blade knife, the skin was incised in the midline, and monopolar cautery was used to dissect through the subcutaneous tissue to open the fascia and reflect the paraspinal muscles laterally, exposing the posterior elements from L1 through L3. Using lateral fluoroscopic imaging, we then proceeded to place Synthes Schanz-type pedicle screws into the pedicles of L1 and L3 bilaterally. Rods were then connected to the implanted pedicle screws, and a two stage reduction maneuver was performed, restoring lordosis intervertebral body height. The L1-2 and L2-3 facet articulations were then decorticated with a Leksell rongeur. The bone harvested from the decortication was packed into the decorticated facet articulations, and two large BMP sponges were then distributed into the facet capsules bilaterally to establish a posterolateral arthrodesis.

The wound was copiously irrigated with antibiotic solution. Lateral fluoroscopic imaging in the AP and lateral projections verified excellent fracture reduction. A subfascial Hemovac drain was placed, and the wound was closed in usual fashion using 0 Vicryl sutures in the fascia, interrupted 2-0 Vicryl sutures in the subcutaneous layer, followed by staples in the skin. A sterile dry gauze dressing was then applied. The patient was extubated in the operating room and transferred to the recovery room in stable condition. There were no complications.

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