Deanna Martinez

Topics: Spinal disc herniation, Surgery, Hernia Pages: 3 (360 words) Published: April 16, 2012

Patient Name: Deanna Martinez

Patient ID: 117232

Date of Surgery: 05/27/----

Admitting Physician: Sheila Goodman, MD, Neurosurgery

Surgeon: Sheila Goodman, MD

Assistant: Markus LeRoy Johnson, PA-C

Preoperative Diagnosis: Lateral recess syndrome at L5-S1, right.

Postoperative Diagnosis: Herniated disk at L5-S1, right.

Operative Procedure: Lumbar laminectomy and excision of disk at L5-S1 on the right.

Anesthesia: General endotracheal plus Marcaine with epinephrine.

Specimen Removed: Lumbar disk tissue.

IV Fluids: 1500 mL crystalloid.

Estimated Blood Loss: Minimal.

Urine Output: 500 mL clear urine.

Complications: None.

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



Patient Name: Deanna Martinez
Patient ID: 117232
Date of Surgery: 05/27/----
Page 2

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 When the root was retracted medially, a rather tall, discrete, cone-shaped disk herniation about 6 mm in height was seen.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 disk tissue was removed using curettes and rongeurs. The disk was fairly healthy. There was quite a bit of disk 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....
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