Reference no: EM133875175

Question

Endotracheal anesthesia was administered, and the back was prepped and draped in the usual fashion. We used intraoperative x-ray to approximate the location of the L4-5 interspace such that we could center the incision over this area. An incision was made over the L4-5 interspace, and the incision carried down through the subcutaneous tissues, which in this lady were quite considerable. The lumbosacral fascia was opened on the left side only, and the paraspinal muscles were stripped subperiosteally to expose the spinous processes and laminae of L4 and L5. We obtained an x-ray with our marker at the L5 lamina. Once this was done, the L4-5 interspace was identified and a left L4-5 partial hemilaminectomy and medial facetectomy were performed. Verifying that was inferior enough sufficiently to be able to reach the L5 nerve root and sequestered fragment. Partially, the bony removal was accomplished also, in addition to the Midas Rex drill. It was performed using curettes and Kerrisons. The yellow ligament was removed, exposing the common dural sac, and I was able to identify the L4-5 interspace, which appeared to be indurated and consistent with a previous disc herniation. The L5 nerve root was identified and was gently mobilized medially, and I was able to identify the sequestered disc, which was actually in three large fragments. These were mobilized with a blunt hook and then delivered with a small pituitary punch. Perhaps the largest of the fragments actually appeared to extend out the foramina along with the L5 nerve root. After the fragments were released, the dura and nerve root appeared to be much more relaxed and I probed out the foramina using both a blunt hook and then a Woodson. No additional fragments were uncovered. I inspected the L4-5 disk with an Epstein curette. There were no additional rents that appeared to be scarred, and rather than risk a second disc herniation through an area that appeared to be already healed, this was left alone. The common dural sac was well decompressed en route. The area was irrigated with an antibiotic saline solution. A small autologous fat graft was harvested and placed over the root and dura and then covered with a Gelfoam thrombin slurry. The wound was infiltrated with 25 percent Marcaine with epinephrine, and the wound was closed by reapproximating the muscles and fascia with O Vicryl: a 2-0 Vicryl subcutaneous closure and a running 4-0 subcuticular stitch in the skin. The wound was reinforced with Steri-Strips. A sterile dressing was applied. Throughout the case the patient remained hemodynamically stable.