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REASON FOR VISIT: • • • • • • • • Back pain Pressure on the lumbosacral nerve roots Weakness Bowel dysfunction Bladder dysfunction Herniated disc Osteoporosis Osteoarthritis
RISK ASSESSMENT • • • • • • • • • • • • • • Pulmonary insufficiency Cardiac insufficiency Mitral valve insufficiency Aortic valve insufficiency Cardiovascular insufficiency Old age Hypertension Dehydration Malnutrition Diabetes Hypothyroidism Bleeding disorder Allergies to medication Allergies to anesthesia
PREPARATION OF THE PATIENT: • • • Blood tests Urine tests X-ray chest
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X-ray spine CT scan MRI Myelogram Aspirin was stopped before the procedure Patient was on fasting for ____hrs before procedure Part was prepared and draped in sterile fashion
ANESTHESIA: • • General anesthesia Local anesthesia
POSITION OF THE PATIENT: • • The Prone Position Lateral Decubitus Position
THE PROCEDURE OPEN • The back was shaved, scrubbed with Betadine scrub, rinsed with alcohol, and prepped with DuraPrep, and draped in the usual sterile fashion with Ioban drape being used. A midline skin incision was made. Dissection was carried down through the subcutaneous tissue. The lumbosacral fascia was split to the left of the spinous process A small amount of bone and ligament from the back of the spine was removed (laminectomy was done) Dura and nerve root were identified and protected with nerve root retractor The herniated disc fragment was removed The disc has been cleaned out from the area around the nerves Check was made for CSF leakage, and no evidence of significant epidural bleeding was present.
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The wound was irrigated with antibiotic solution. Twenty milligrams of Depo-Medrol was placed over the dura and nerve root. A free fat graft from the subcutaneous tissue was then placed over the dura. Closure was obtained with the lumbosacral fascia being reapproximated with #1, running, and Vicryl suture. Subcutaneous closure was obtained in layers with 2-0, running, Vicryl suture. Skin closure was obtained with 3-0 Vicryl subcuticular suture. Proxi-Strips and sterile dressing was applied. The skin had been infiltrated with 8 mL of 0.5% Marcaine with epinephrine.
LASER DISCECTOMY • • • • • • • Part was prepared and draped Local anesthesia was given at the site of surgery Patient was in the prone or lateral decubitus position The disc space was identified with the help of a C-arm fluoroscope. Disc margins were made clear by craniocaudal movement of the fluoro tube. At this time, the fluoro tube was rotated obliquely to bring the superior articular process to the mid line. An 18-gauge 7-in needle was introduced immediately anterior to the superior articular process and superior to the transverse process via a triangular safe zone. The needle was advanced in 1- to 2-cm increments in a "stop and look and go" process, to allow a change of course if it is not directed properly. The needle tip was at the center of the disc upon completion. The rubbery texture of the annulus was easily felted with the tip of the 18-gauge needle. Laser application
The needle was reached the annulus, advanced it through the annulus and into the nucleus pulposus for a distance of approximately 1 cm. The fiber was marked to prevent penetration of the tip more than 1 cm beyond the end of the needle. The laser was applied as energy levels of ____ W, with __pulses, until ___________ J was delivered for ______seconds Fluoroscopic images were taken The needle was removed slowly
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AFTER PROCEDURE: • • Patient was shifted to the intensive care unit Blood pressure, temperature, pulse rate was monitored
DURATION _______hrs POSTOPERATIVE CARE • • • • • • • • • • • Take antibiotics as prescribed Take pain medication as prescribed Must lie on prone position Sleep on a firm mattress Avoid bending at the waist Avoid lifting heavy weights Avoid sitting for long time Use a reclined chair Avoid bending, twisting, lifting heavy objects Begin exercise after two weeks Keep the dressing clean and dry
COMPLICATIONS • • Infection Bleeding
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Injury to the nerves Injury to the blood vessels Paralysis of leg Bladder weakness Discitis Subchondral marrow abnormalities Persistent of pain Deep vein thrombosis