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SURG&R,Y INFORMATI ON :Date of Surgery

Primary Diagnosis (Code)Thoracic or l umbos ac r a l neuri t1~ or r adi cul i t i s, unspecifPrim~ ProCedure (Code)TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) , ANTERIOR APPROSeoondary Prooodur8

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DISCHARGE SUMMARY

Post op day two - - The pat ient was afebrile. Whi te count is 13.9. H&H is 11.9 and 35.6. A.M. labs areintact . No radicula r pain in the lower extremities and expected abdominal and low back pain.

Internal discdisruption LS-S1.

Internal disc disrup tion L5-S1.

1. Total disc replacement arthroplasty L5-S1.2. Thecal sac decompress ion LS-S1.

PROCEDURE:

PAT IENT NAME:MR#:ADMIT DATE:DISCHARGE DATE;

SURGEON:

INDICATIONS FOR PROCEDURE: The patient is a 36-year-old Hispanic female seen in my officeregardlng severe loW'er back and lower extremity pain. She has been refractory to conservative modalitiesDiagnostic imaging support s the above diagnosis. The patient wished surgi cal intervention.

ADMISSION DIAGNOSIS:

DISCHARGE DIAGNOS IS:

ASSISTANT:

Post op day one - - The patient was afebrile. The dressing was changed. The incision site is clean,dry, and healing well wilh no signs of Infection. No lower extremity radicu lar pain. All radicular symptoms are gonewith the proced ure. Increase out of bed activity. Progress is satiSfactory to dale. Discontinue the Foley calheter inthe a.m.

Post op day three - - The patient was afebr ile and vital signs stable. Lower extremity radicularsympto ms are gone and low back paIn Is lessening . Appetite is good. The patient Is independent with ambulation.

HOSPITAL COURSE: Surgery was carried out on the day of admission withoutcomp lication or problems . Her postoperative course has been uneventful.

DISCHARGE INSTRUCTIONS: FIJI! discharge instrl,Jctions were given. All quest ions wereanswe red to the patient'S satisfaction. Discharge home today with medications of Norco 10/325 for pain dispe nsed90, one every four to six hours p.r.n. pain and take with food, Flexeril 10 mg dispensed 60. one p.o b.i.d, to I.I.d.~uscle spasms. Questions or problems, the patient knows to contact us right away. We will see her on_ of next week for dressing change, wound inspection, re-x-ray , and reexamination.

OPERATIVE REPORT

Internal disc disruption L5-S1.

Internal disc disruption l S·S1.

Minimal.

None.

Generaloral endotracheal-

PATIENT NAME:MR#,ADMIT DATE:PROCEDURE DATE:

POSTOPERATIVE DIAGNOSES:

PREOPERATIVE DIAGNOSES:

ANESTHESIOLOGIST:

ESTIMATED BLOOD LOSS:

COMPLICATIONS:

ANESTHESIA:

NARRATIVE: The patient is a 36-year-old Hispanic female seen In myoffice on referral Irom Dr. regarding severe low back pain. She states she suffered a workrelated injury 10 her spine on A passenger struck her with a 66 pound object andhit her abdominal area. She has had problems with the area ever since. She has had epidural steroidinjections with Dr. Dr. _ wanted to perform an IDET procedure and that was notallowed. She saw Dr. who treated her with a Medrol Oosepak, trigger point injections, traction,physical therapy with some measure of relief and she states her low back has not improved. Dr.was not on the _ network and she switc/'led to Dr. for further care and senI le

in---...- She states she is not having any significant iiress. She hasundergone lumbar discography on by Dr. at at~~~~iiilhat showed a normal disc at l 4-5 and posterior disc protrusion wilh extravasation on dyeand reproduction of back pain at l 5-S1 . Treatment options were discussed and reviewed with thepatient at length. The nature of the condition. inherent risks. complications. options, and benefitsassociated with the procedure including surgical and conservative management and surgical optionsreviewed and discussed and the patient wished to pursue total disc replacement arthroplasty. Sheunderstands the possibility of infection. continued pain, no clinical improvement. need for additionalprocedures in they Mure, these and other potentialities discussed and reviewed and informed consentobtained. There have been no promises as to outcome or cure.

ASSISTANT;

CO-SURGEONS:

PROCEDURE:1. Total disc replacement arthroplasty l 5-S1Ievel - _2. Fluoroscopy under one hour time - 76000.3. EMG MEP testing bilateral lOWer extremities -

PROCEDURE; The patient was laken to the operaling room, put on theoperative streicher and placed on the operating table in the supine position. Under IV sedation, thepatient wasorally h tubated by Mr. and generalanesthetic administered.

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A Foley catheter was inserted in her bladder under strict sterlle technique as per protocol by theoperative nursing staff. The patient received Ancsf one gram IV piggyback prior to the start of theprocedure.

Long TED hose and foot pumps were placed on the bilateral lower extremities. They were all properlyeushloned and weight relieved. EMG motor evoked potential testIng electrodes were administered byMr._under my direction and these tests were carried out throughout the procedure. The arms wereabducted away from her side just short of the horizontal. The lower abdominal area was shaved just tothe level above the pubes. The abdominal area was sterilely prepped as per standard technique. Dr.

Hadea midline incision from the umbilicus just short of the hairline and electrocautery was used toobtain good hemostasis. See his notes for further details regarding exposure of the anterior lumbarspine by anterior retroperitoneal approach. Dr._placed Steinmann pins into the vertebrae of L5 andS1 with lap sponges wrapped around these pins connected to the Burchwalter self retaining retractorwith the appropriate retractor blades in place. The L5-S1 disc level was identified and confirmed withplacement of Steinmann pin in the disc space on AP and lateral projection.

The midline was marked with electrocautery and the anterior aspect of the L5 vertebrae.

A #10 blade long knife handle was used to make an anterior annulotomy incision at L5-S1. The Cobbelevator was used to elevate the disc off of L5 and $1 . F'ituitary rongeur double action narrow Lexelrongeur was used to remove the disc material. A ring curette and angled curette was used to remove thedisc material and cartilaginous end plate off of L5 inferior and S1 superiorly. The posterior annulus wasreleased with an angled curette at L5 and S1 to release it off these vertebral bodies so distraction couldbe obtained at this level. Interbody spacing templating pre and intraoperatively showed a 2 wideprosthesis to be the most appropriate and T" lordosis. The trial implant was selected and placed andfound to be appropriately size on both AP and lateral C-arm fluoroscopic views and clinically with testingon the insertion handle. This was removed. The end plates were fully denuded. Bleeding bone on theend plates was exposed. The DePuy Charite disc replacemenl arthroplasty end plates conforming tothose dimensions were opened and placed on the insertion device and placed in an anterior 10 posteriorfashion. It should be noted the spinal thecal sac was decompressed anteriorly via the completediscectomy. The insertion handle for the end plates gave us additional distraction and the rotatorpaddles were used 7.5 and 8.5 mm core distraction was carried out. The wound was copiously irrigatedwith sterile saline inclUding now and suctioned dry. An 8.5 mm core for the Chante total discreplacement arthroplasty was opened and placed on the insertion device and placed between the twoend plate prostheses and the distraction/inserter device was released back to neutral and gentlyremoved. Wiley renal vein retractors were repositioned as well to insure full retraction of vascularelements. The appropriate alignment on both AP and lateral C-arm fluoroscopic view of the discreplacement was noted. Surgical and adhesions barrier was placed over the implant at L5-S1 and theSteinmann pins and Wiley renal vein retractors were all removed. There was no injury to the iliacvessels or the sympathetic chain during the procedure. All sponge and needle counts were correct. Or._ commenced his repair of the anterior retroperitoneal approach at LS-81 . The skin was closed withrunning subcuticular stitch of 4~O Vicryl and covered With Mastisol. Steri~Strips. Xeroform, 4X4's, andtape.

The patient was discontinued from anesthesia, orally extubated on the table and transported on therecovery stretcher to the recovery room in apparent satisfactory condition.

The patient tolerated the procedure well. There were no complications encountered intraoperatively. Allsponge and needle counts were correct.

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