OPERATIVE REPORT

PATIENT NAME
Deanna Martinez

PATIENT ID
117232

DATE OF SURGERY
05/27/2019

ADMITTING PHYSICIAN
Shelia Goodman, MD, Neurosurgery

SURGEON
Shelia Goodman, MD

PREOPERATIVE DIAGNOSIS
Lateral recess syndrome at L5-S1, right.

POSTOPERATIVE DIAGNOSIS
Herniated disc at L5-S1, right.

OPERATIVE PROCEDURES
1. Lumbar laminectomy.
2. Excision of disc at L5-S1 on the right.

ANESTHESIA
General endotracheal plus Marcaine with epinephrine.

SPECIMEN REMOVED
Lumbar disc tissue.

IV FLUIDS
1500 mL crystalloid.

ESTIMATED BLOOD LOSS

Minimal.

COMPLICATIONS
None.

(Continued)
OPERATIVE REPORT

Patient Name: Deanna Martinez

Patient ID: 117232
Date of Surgery: 05/27/2019
Page 2

PROCEDURE IN DETAIL
Proper informed consent obtained, operative site initialed. With the patient
under general endotracheal anesthesia in the prone position in the Cloward
saddle, the skin of the back was prepared in the usual sterile manner and
draped with Vi-Drapes.

A midline incision centered over L5-S1 was made and carried down to the
fascia. Marcaine 0.25% with epinephrine was injected; the fascia was incised
alongside the L5 spinous process and the muscle was stripped off laterally. A
portion of the lamina of L5 was removed, and the ligamentum flavum was
incised and excised. The S1 root was immediately apparent and appeared to
be contused. When the root was retracted medially, a rather tall, discrete
cone-shaped disc herniation about 6 mm in height was seen. The posterior
longitudinal ligament was incised, and the fragment was removed.

The interspace was then entered, and disc tissue was removed using
curettes and rongeurs. The disc was fairly healthy. There was quite a bit of
disc tissue. The wound was then irrigated with Kantrex. A Gelfoam sponge
was left in place. Closure was done with 2-0 Vicryl in both the fascia and
subcutaneous tissue. Then 4-0 undyed Vicryl was used as a subcuticular
stitch. Sterile dressing was applied.

The patient tolerated the procedure without incident and was taken to PAR in
satisfactory condition. Once she passes all criteria, she will be transferred to
SICU for 24 hours’ observation.

Sheila Goodman, MD
Neurosurgery

SG:AI
D: 05/27/2019
T: 05/28/2019