Operative dictations pdf download f

Insert blade into the head at correct angle 7. Make cut at preplanned level usually just above lesser troch 8. Bring down the blade and secure to the shaft, derotate as needed 9. Check position with fluoro 31 S. Her acetabu- lum has failed to develop adequately and her hip is slightly sublux- ated.

Abduction views showed that the head can be well contained. After discussion with her parents, the decision was made to proceed with varus osteotomy of the proximal femur to redirect the femoral head deep into the acetabulum.

Description of Operation: The patient was properly identified by anesthesia and positioned supine on the flat table. Anesthesia was administered. A longitudinal incision was made from the tip of the greater trochanter, 8 in. The fascia lata was divided in line with the incision. The vastus lateralis was detached from its origin at the vastus ridge and retracted anteriorly with a homan retractor placed directly on the anterior femur.

The anterior neck was bluntly dissected and with a finger along the neck, a k-wire was directed along the anterior neck into the head. A guide wire was inserted into the tip of the greater trochanter and a second wire near the knee to subtend the intended arc of derotation. The position of the wire in the center of the next was confirmed on frog lateral fluoroscopy.

Next, the chisel was inserted over the wire 10 mm at a time and removed in order to prevent incarcera- tion of the chisel. With retractors around the femur, the cut was made 1 cm below the blade insertion site. The blade was then inserted over the wire. The neck was tipped into varus until the plate came into contact with the distal fragment with the femoral shaft slightly displaced medially. The distal fragment was rotated until the reference wires are parallel.

The plate was secured with screws. Final position was confirmed with fluoroscopy. The wound was irrigated with sterile saline. The vastus was re-approximated with 0-vicryl interrupted sutures.

The fascia lata was closed with a running 0-vicryl and the subcutaneus layer with a running vic- ryl. The skin was closed with a running monocryl subcuticular stitch and steri-strips. A sterile dressing was applied and then a one and one-half hip spica cast. Hamstrings lengthening can be isolated or combined with other tendons lengthening. Prone positioning in isolated hamstring lengthening.

A single midline longitudinal incision just superior to the popliteal fossa. Identification of the three hamstrings.

Z-plasty of the semitendinosis. Fractional lengthening of the semimembranosis and the biceps femoris. Apply cast in amount of extension that can be obtained without force. No flexion contracture of the hip. No equinus deformity Procedure: Hamstrings lengthening Postoperative Diagnosis: Same Description of Operation: The patient was brought to the operat- ing room supine on the stretcher. IV antibiotics were given, and a well-padded thigh tourniquet was placed.

After adequate general anesthesia was provided, the patient was rolled to the prone posi- tion on the operative table and all pressure points were padded. The patient lower extremity was then prepped and draped in the standard surgical fashion.

The lower extremity was exsanguinated with an Esmarch bandage and the tourniquet was inflated to mm Hg. A 10 cm midline, longitudinal skin incision was performed starting proxi- mal to the polpliteal crease.

The subcutaneous fat was divided protecting the posterior femoral cutaneous nerve in the proximal portion of the wound. The semitendinosis was identified medially. A Z-lengthening of the tendon was performed. The semimembra- nosis was then identified deep to the semitendinosis. A fractional lengthening was performed at the musculotendinous junction with the tendinous portion divided transversely at two levels, 3 cm apart.

The biceps femoris was then identified on the lateral side. A similar fractional lengthening was done taking into consideration to stay away from the common peroneal nerve. The wound was then irrigated. The tourniquet was deflated and hemostasis obtained with electrocautery. The subcutaneous tissue was closed with 2. The skin was closed with monocryl in subcuticular fashion.

A clean dressing was applied, followed by a long leg cylinder cast. The cast is removed in 4 weeks and physical therapy started.

Knee immobilizers are used for approximately 8—12 weeks postoperatively. Preoperative planning. Supine position on a radiolucent table.

Fibula osteotomy. Incision on the medial side of the proximal tibia. Outline the osteotomy with drill holes 6. Completion of the osteotomy. Angular correction. Cast application. After adequate general anesthesia was provided, a well-padded thigh tourniquet was placed. The lower extremity was then prepped and draped in the standard surgical fashion. A 15 blade was used to make a 5 cm longitudinal incision in the middle third of the leg over the fibula. The bone was exposed subperiosteally and a 2 cm segment was resected.

Prophylactic anterior compart- ment fasciotomy was next performed. The wound was closed in two layers: vicryl 3. Then an 8 cm medial, longitudinal incision centered on the metaphyseal diaphyseal junction of the proximal tibia was made. A circumferential periosteal stripping of the bone was performed.

The osteotomy was outlined with 2. The holes started medially, crossed the midline perpendicu- lar to the axis of the bone before shaping the spike on the lateral side. The spike had a height of 3—4 cm and a base of 1—1. The drill holes were connected with an osteotome taking care not to fracture the spike. Once the osteotomy was completed, the distal fragment was angulated laterally and the spike was impaled into the cancellous bone of the metaphysis. Fluoroscopy confirmed the adequacy of the correction.

The wound was thoroughly irrigated with saline and was closed in anatomic layers; the periosteum with interrupted 2. A long leg cast was applied to maintain the correction. Fluoroscopy was used again to assess the fragments position before extubation of the patient. First cast in supination 2. Series of 3—4 abduction casts changed at weekly interval 3. Percutaneous Achilles tenotomy to correct equinus 4. The child is brought to the procedure room. No anesthetic needed. Allow the infant to feed during the casting process.

Soft roll is applied from the tip of the toes to the proximal thigh. Care is taken to avoid excessive padding. Plaster is applied 37 S. Anatomic molding is carried out in the popliteal fossa. Second to fourth cast: The child is brought to the procedure room. Allow the infant to feed during the manipulation and casting processes. The talar head is localized in front of the lateral malleolus. It is stabilized by the thumb while the index of the same hand is placed behind the lateral malleolus.

The foot is then abducted as far as can be done without causing discomfort to the infant. The pres- sure is maintained for 1 min. After 3—4 manipulations, soft roll is applied from the tip of the toes to the proximal thigh. Plaster is applied as a below-knee cast while the foot is abducted and counterpressure is applied over the head of the talus serving as a fulcrum.

The cast is molded gently along the Achilles tendon and the malleoli. Similarly, the child returns on a weekly basis for removal of the cast and progressive correction with further abduction. Achilles tenotomy: Emla gel is applied over the posterior ankle for 15 min. Then the child is placed prone and the foot or feet is prepped and draped in a sterile fashion. A beaver blade size is introduced medial to the Achilles tendon, 1.

The knife is withdrawn, pressure is applied to the wound for 5 min to stop the bleeding, a steristrip adhesive is applied. Postoperative care: The last cast applied for 3 weeks.

There are numerous incisions described and this is a topic of great debate. The remaining steps are done in sequence as needed. Not all may be needed. Expose achilles tendon within the sheath 2. Z-lengthening of the achilles tendon. Repair later 3. Open posterior compartment looking for FHL 4.

Subperiosteal dissection under FHL around medial side of ankle and subtalar joint 5. Open peroneal tendon sheath to tip of lateral malleolus 6. Incise the capsule in the entire area just exposed 39 S.

Release proximal attachment of abductor hallucis 2. Expose FDL and tibialis posterior from the medial malleo- lus to the knot of Henry 3. Detach posterior tibial tendon 4. Open the calcaneocuboid joint capsule 6. Divide plantar fascia behind the neurovascular bundle, just off the insertion of the calcaneus 7. Pin talonavicular joint 8. Second pin from calcaneus, through talus, into the tibia 9.

Reattach PTT. Shorten lateral column either through either the calca- neocuboid joint or bone. This foot is very stiff and resistant to treatment. After discussion with his par- ents, the decision was made to proceed with surgical correction. Description of Operation: The patient is positioned prone.

A posteromedial incision was made. The sheath was opened and the achilles tendon was subsequently divided in a Z-lengthening fashion.

The neurovas- cular bundle and tendons were protected while the capsule was incised into the tibiotalar and subtalar joints. Care was taken to protect the cartilagenous surfaces at this point. Next, the PTT was taken off the navicular taking care to protect the insertion of per- oneus longus.

These were then divided in a z-fashion for later repair. The plantar fascia was release just off the calcaneus behind the neu- rovascular bundle with a retractor protecting it. The talonavicular and calcaneocuboid joint capsules were opened completely.

The foot was noted to be plantigrade at this point in time and the wound was then thoroughly irrigated. We did not feel a lateral column shortening would be needed. A second wire held the talonavicular joint in a reduced position. The wound was then closed with Vicryl approximat- ing the subcutaneous fat and Monocryl approximating the skin edges in a subcuticular manner. The wound was then cleaned and covered with sterile bandages.

The leg was then overwrapped with Xeroform and sterile Sof-Rol and a short leg cast was then applied. Position patient supine. Incise longitudinally along medial border of the anterior tibial tendon.

Dissect out the tendon as distal as possible before disinsertion. Incise longitudinally over the third cuneiform. Pass the tendon from medial to lateral deep to the exten- sor retinaculum. Pass the suture through the bone hole out to the plantar aspect of the foot.

Feed the tendon into the bone hole as the suture is pulled taught. Tie the suture over adaptic, sterile foam, and then a button. All bony prominences of the patient were well padded and protected. The tourniquet was placed up to mm of mercury.

A 5 cm longitudinal skin incision was made medial and parallel to the distal part of the tibialis anterior, and sharp dissection was carried down to the level of the tendon sheath. The tendon sheath was incised longitudinally, and the tibialis anterior tendon was isolated. The tibialis anterior tendon was dissected off its insertion as distally as possible. Two Keith needles were used to place a stay stitch on the tendon. Next, a longitudinal incision was made over the third cunei- form.

Sharp dissection was carried down to the level of the periosteum. A periosteal elevator was utilized to move any periosteum and cartilage that was overlying the bone. Next, a hemostat was placed underneath the extensor reti- naculum of the ankle proximally and spread underneath the retinaculum. The tibialis anterior tendon was grasped by the stay sutures and pulled underneath the extensor retinaculum.

Both wounds were irrigated copiously with normal saline. The extensor retinaculum was closed with Vicryl , the subcutane- ous with Vicryl , and the skin with Monocryl in a running simple fashion. A sterile dressing was applied followed by a long leg cast. The tourniquet was let down. The patient was extubated and was transferred to the postoperative recovery room without any evidence of immediate complications. Posteromedial incision 2.

Splitting of the posterior tibial tendon 3. Lateral incision 4. General anesthesia was induced by the anesthesia team. A tour- niquet was applied. The extremity was prepped and draped from the knee to the toes in the usual sterile fashion. With a 15 blade, a posteromedial ankle incision was performed. It started 7 cm proximal to the tip of the medial malleolus slightly posterior to the medial tibia cortex to terminate distally 1. The sheath was incised. The tendon was split longitudinally into two halves by blunt dissection.

The plantar half of the tendon was sectioned at its navicular insertion and pulled proximally. A separate curvilinear lateral incision was performed. The peroneal tendons were exposed. The sheath of the per- oneus brevis was incised. With an Ober tendon passer, the split segment of the posterior tibial tendon was passed from the medial to the lateral wound behind the tibia. It was sutured to the peroneus brevis tendon with 0 Ticron under tension.

The tourniquet was released, hemostasis was achieved, and the wound was closed in anatomical layers: subcutaneous tissue with vicryl and skin with monocryl. Sterile dressings were applied followed by a short leg cast with the ankle in neutral position and the heel in slight eversion. Post-op regimen: cast for 3—4 weeks. Position—supine on fracture table—opposite leg extended and abducted. Make sure subchondral bone and physeal plate are visible.

Angle pin anterior to posterior. Advance pin no closer to subchondral bone than 5 mm. Drill, tap, and advance screw should be at least 6. Anesthesia was induced. Prophylactic antibiotics were administered. The patient was placed supine on the fracture table in minimal skin traction. The opposite leg was abducted and extended. Fluoroscopy was used to verify appropri- ate visualization of the hip, subchondral bone, and physeal plate in the AP and lateral planes.

The patient was then prepped and draped. A free pin was placed over the hip to verify AP orientation of the femoral neck and a line drawn along the pin. A second line was then drawn in line with the femoral neck on the lateral view. The incision was then made centered on the intersection of the lines.

The incision was carried through subcutaneous tissues, the fascia, and through the vastus lateralis. Then a guide pin was inserted centered in both the AP and lateral planes, taking care to aim slightly anterior to posterior to take into account the posterior displacement of the epiphysis. The guide wire was advanced just short of the subchondral bone, measured, overdrilled, and then overtapped.

The wound was then irrigated, closed in layers, and ster- ilely dressed. Careful preoperative assessment history, physical examina- tion—evaluation of compartment syndrome, radiographs 2. Closed reduction 3. Cross pinning 4. Description of Operation: The patient underwent anesthesia per the anesthesia team. The upper extremity was prepped and draped in the usual sterile fashion. With the elbow extended, gentle longitudinal traction was applied to the supinated forearm, with counter traction applied to the upper part of the arm by my assistant.

The frontal plane displacement and the rotation were corrected while maintaining the longitudinal traction. The distal pulses were palpable at the end of the procedure. Post-op regimen: Hospitalization 24—48 h with strict elevation of the upper extremity. The patient needs K-wires removal under general anesthesia in 3 weeks. Careful preoperative assessment history, physical examination—evaluation of neurovascular structures, radiographs 2.

Attempt for closed reduction 3. Open reduction through medial, possible lateral incision 4. Cross pinning 5.

Description of Operation: The patient underwent general anesthesia per the anesthesia team. The patient was positioned supine with the shoulder at the edge of the table and the involved extremity resting on a radiolucent arm table.

A longitudinal incision 3- to 4-cm long was made over the medial side of the distal end of the humerus and elbow. There was no neural or vascular structure entrapped between the two fragments. A lateral longitudinal incision was made over the lateral con- dyle of the distal end of the humerus to allow exposure of the lateral side of the fracture.

Reduction was achieved successfully under direct vision from both wounds. The medial K-wire was repositioned and a similar lateral one was inserted from the lateral epicondyle and oriented medially and cephalad. The two wires crossed proximal to the frac- ture side. The wires were bent and buried under the skin.

The incisions were closed in two layers; the subcutaneous layer with vicryl and the skin with monocryl in subcuticular fashion. The wounds were covered with steri-strip s and a sterile dress- ing. Administer general anesthesia.

Palpate iliac crests, and mark target level with pen. Make vertical midline incision over spinous processes, and then dissect lateral to spinous processes on affected side down to laminae using electrocautery, and a Cobb elevator for retraction.

For exposure, remove additional respective portions of laminae and medial facet joint capsule, with upbiting ron- geur, if necessary, then expose dura, and dissect from medial portion of dura laterally to identify the affected nerve root with care to not mistake the lateral border of the dura for the nerve root when disc herniations occur medial to the nerve root.

Inspect neural foramina, check that nerve root remains free from tension allowing for at least 1 cm of medial dis- placement, irrigate wound, and place fat graft.

Pain exacerbating with coughing and straining. Quality of life impaired with inability to work desk job. Conservative therapy unsuccessful. The patient was gently log-rolled to and positioned prone on the Wilson frame. Care was taken to protect and pad all pres- sure points. The back was sterilely prepped and draped. A midline longitudinal incision was made over the lumbosacral junction.

Sharp dissection was carried through subcutaneous tissue with hemostasis controlled with electrocoagulation. Paraspinal muscles were subperiosteally elevated from the affected lateral side of the spinous processes at that level. The undersurface of the caudal portion of the lamina of L4 and the cranial 3 mm of L5 were cleared. A laminotomy involving the caudal 3 mm of L4 and the cranial 3 mm of L5 were then undertaken. Portions of the medial facet capsule were removed to allow satisfactory vis- ualization laterally.

Upon entrance to the epidural space, the con- tents of the canal were protected at all times with square cottonoid patties. It was retracted toward the midline and there was immediate visualization of a large extruded disc portion within the canal. Large epidural bleeders were controlled with bipolar electrocoagulation. Multiple fragments of disc material were removed including the largest ones measuring approximately ….

The posterior boundary of the body of L5 and S1 were probed and found to be free. It could easily pass ventral to the thecal sac. The wound was irrigated with antibiotic irrigant. The patient underwent forceful Valsava maneuver and there was no expression of CSF. A fat graft was harvested subcutaneously. The exposed thecal sac and root were bathed with combined depo-medrol and marcaine. Exposed boundaries of the thecal sac were covered with sub- cutaneous fat graft.

The Taylor retractor was removed and the par- aspinal muscles allowed to fall into their anatomic position. Subcutaneous tissue was closed in layers with Vicryl followed by a Monocryl running suture for skin closure.

Steri-strips and sterile dressings were applied. The patient was gently log-rolled, transferred to a hospital bed, extu- bated, positioned with the head of bed elevated, and transferred to the recovery room in stable condition. Sponge and needle counts were correct, times two.

Staff Faculty Surgeon was present, scrubbed, and partici- pated actively in every aspect of the procedure. General anesthesia 2. Patient positioned proned on Wilson frame 3. Posterior approach to spine 5.

Decompression performed resection of spinal lamina 7. Nerve roots assessed for stenosis 8. The pain-free walking distance is less than one block. Foley catheter and appropriate IV lines were placed. Patient was then gently log rolled into position prone on the Wilson frame. Care was taken to protect and pad all pressure points. Fluoroscopy was used to determine the proper levels of stenosis and to draw the incision.

The back was then prepped and draped free in the usual sterile fashion. A midline longitudinal incision was made over the lower lumbar spine. Sharp dissection was carried through subcutaneous tissue, with hemostasis controlled with electrocoagulation. The paraspinal muscles were subperiosteally elevated from the lateral side of the spinous processes. Dissection continued laterally so as to expose the facet joints.

The dorsal lamina was then thinned with a high-speed burr. Upon entrance into the epidural space, there was complete absence of epidural fat. The thecal sac throughout the surgical procedure was protected with cottonoid patties. This greatly freed the lateral recess. The wound was then copiously irrigated, including antibiotic irrigant. Patient underwent force of Valsalva maneuver.

Soft retaining retractor was removed, and the paraspinal muscles are allowed to fall in their anatomical posi- tion. Vancomycin powder was applied. A drain is applied. Subcutaneous tissue was closed in layers with Vicryl, followed by skin closure with Monocryl. Steri- strips were applied, followed by a dry sterile dressing.

The patient was then gently log rolled into supine position on the hospital bed, extubated, and taken to the recovery room in sat- isfactory condition, having tolerated the procedure well. Midline incision. Dissect subperiosteally down the lamina to the level of the facet joint.

Clear facet joint one level cranial but do not strip the capsule off this joint. Continue dissection out laterally at both levels to the tips of the transverse processes. Decorticate the pars and transverse processes. Strip the capsule of the facet joint to be fused and remove cartilage from within the joint. Lay strips of corticocancellous autograft cancellous side facing ventral between the transverse processes and along the pars and lamina. Insert pedicle screws.

Starting point is at a point where a line down the trans- verse process intersects a line up the pars. This usually corresponds to the most caudal portion of the superior facet of the level below. Angle in varies depending on the level. Cant c-arm to get a perfect shot down the pedicle and make start point with burr.

Do not go beyond half way across the vertebral body on the lateral. Tap the hole. Check for breach of all four walls and the distal part of the hole with feeler. Insert screw. Connect screws depending on type of construct chosen. He has exhausted all conservative measures and would like to proceed with fusion.

He is aware of the risks and the rela- tively low chance of complete relief and is willing to proceed. General anesthetic was delivered and he was intubated. He was log-rolled onto the Wilson frame. All pressure points were padded.

Antibiotics were given. The back was prepped and draped in the usual fashion. Dissection was then car- ried down the lamina of L4 and L5 bilaterally to the level of the facet joints. A Cobb elevator and cautery were used to proceed on out to the tips of the transverse processes.

A burr was used to decorticate both transverse processes and the pars. Next, the previously harvested corticocancel- lous autograft was cut into strips and laid down from transverse process to transverse process and across the lamina and pars.

Next attention was directed to the placement of the pedicle screws. We began with the L4 pedicle. This was at the most inferior portion of the superior facet of L5. The starting point was made with a burr and the pedicle entered with a blunt gear shift. On the lateral, we stopped at the midway point of the vertebral body.

The hole was tapped to the same level. Next the screw was inserted. The remainder of the screws was inserted in the same manner. Finally, the screws were con- nected with the rod construct and cross-linked.

Final radiographs were taken and the wound irrigated. The fascia was closed tightly with interrupted 0-vicryl suture. The subcutaneous layer with a running vicryl and the skin with a monocryl running sub- cuticular.

A sterile dressing was applied and the patient was turned back into the supine position and awoken from anesthesia. Endotracheal intubation in supine position.

Prophylactic antibiotics administered. Position patient in lateral decubitus. Flex table to widen costo-iliac region. Iliac crest bone graft is harvested through posterior approach. Begin incision from between the 11th and 12th ribs extending obliquely towards the lateral margin of the rec- tus abdominus, midway between the umbilicus and the symphysis. Carefully incise the fascia and fibers of the external, inter- nal obliques, and transverse abdominus muscles.

Detach the peritoneum by blunt dissection; take care to not enter the pleural cavity. Retract the abdominal contents with a malleable retractor. Expose the psoas muscle.

Identify the genitofemoral nerve and then identify and retract the ureter medially. Palpate the aorta and retract it medially exposing the lat- eral aspect of the lumbar spine. Identify the sympathetic chain crossing longitudinally and the segmental vessels transversely.

Ligate and divide the segmental vessels halfway between the aorta and foramen. Expose all vertebral bodies to be instrumented. Carefully place temporary distraction. Remove disc material from discs above and below involved body. Create trough for cage in vertebral body with burr. Assemble cage and pack with autograft. Place cage and remove distraction device. Size and place lateral plate and screws into vertebral bod- ies above and below to secure fixation of cage.

Carefully close wound reapproximating each layer individually. The patient was placed supine on the operative table and the patient identified the operative site and procedure to be done.

The patient was then gently induced into general anesthe- sia and an endotracheal tube was placed. An axil- lary roll was placed and all bony prominences were well padded. The patient was given perioperative antibiotics. The patient was then prepped and draped in the normal sterile fashion. A posterior longitudinal incision was made over the posterior iliac crest, 2—3 cm lateral to the PSIS.

The posterior muscular fascia was then exposed and the fascia was incised in line with the crest, directly over the crest extending down to bone. The soft tissue was packed away from the bone and an osteotome was utilized to obtain cortical cancellous strips of autograft bone.

A currette was then utilized to remove the cancellous bone down to the inner table. Hemostasis was then obtained with bone wax. The periosteum and posterior muscle fascia were then closed in an interrupted fashion as was the subcutaneous tissue. The skin was then closed with an oblique incision and was then made extending from the … intercostal space posteriorly to the lateral border of the rectus abdominus anteriorly midway between the umbilicus and the pubic symphy- sis.

The external, internal, and transverse abdominal muscles were then incised in line with the incision. Hemostasis was obtained with electrocautery and suture ligature.

The peritoneum was care- fully detached with blunt dissection from the abdominal wall and the abdominal contents were retracted medially with packing and a malleable retractor.

The psoas muscle was then identified and exposed. The genitofemoral nerve was also identified and pro- tected. The ureter was identified and retracted medially. The aorta was then identified, protected, and retracted exposing the verte- bral column.

The sympathetic chain was identified along with the segmental vessels. The vessels were ligated half way between the aorta and the foramen.

The lateral column of the vertebral bodies were cleaned of soft tissue. Any bone that was determined to be compressing the canal from anteriorly on preoperative films was removed carefully. The appropriate size cage was chosen, assembled, and then packed with previously obtained autograft. The cage was then placed in this space and lamina spreaders were removed. Care was taken to insure the correct placement of the cage.

Bone graft was placed anteriorly and laterally but not posteriorly to the cage. These were measured and then tapped. Blunt tipped instrumentation screws were then placed. Two rods were then measured, cut, and placed connecting the screws.

The locking bolts were seated into position with hand tightening. The transverse abdominus, internal, and external oblique musculature were closed in separate layers, in a water tight fashion.

Final sponge count was correct. A sterile dressing was applied. The patient was transferred to the postoperative bed and awak- ened from general endotracheal anesthesia without incident. The patient was extubated and taken to the post-op recovery room in good condition without evidence of immediate complications. Incision through skin, platysma 2. Identification of carotid sheath as dissection is carried out 3. Deeper dissection to identify esophagus and trachea 4.

Further dissection to prevertebral fascia 5. Identification and confirmation of appropriate cervical level s 6. Discectomy 7. Measurement of intervertebral disc space and placement of allograft 8. PDGF application 73 S. Placement of plate and screws, alignment and fixation confirmation Informed consent was obtained. Description of Operation: The patient was identified by the Anesthesia Team and brought to the main operating room.

General anesthetic was administered via the endotracheal tube, and 1 g of Ancef was administered via the IV. The patient was then transferred to the Jackson table where Gardner-Wells tongs were applied. The patient was placed in 7 lb. The shoulders were taped distally, and the neck was positioned in neutral to slight extension. The patient was then prepped and draped in the standard surgical fashion.

Somatosensory evoked potentials were performed throughout the procedure. There was a good wave form, and there were no changes noted by the technician. An anterior approach to the neck was performed from the left side at approximately the level of C5. The skin incision was approximately 5 cm in length. Dissection was carried down through the platysma muscle and just medial to the sternocleidomastoid and carotid sheath.

It was carried down lateral to the strap muscles and esophagus. Dissection continued down to the prevertebral fascia, and fluoroscopy was used to localize the levels of C and C The interspaces were well visualized, and the anterior aspect of the anulus was removed from first the level of C The inter-disk material was removed with a pituitary rongeur and curettes. The high-speed burr was used to further prepare the endplates. Large posterior osteophytes were noted at this level, and were undercut with a 2 mm diamond burr.

The 4. The wound was copiously irrigated, and good hemostasis was achieved. The interspace measured 6 large. The 7 mm large graft was soaked in the platelet concentrate growth factor solution and was impacted into position at C The AP and lateral fluoroscopy verified the excel- lent alignment.

Attention was then turned to the next proximal level of C The interspace was prepared in a similar fashion, taking care to carefully remove the posterior osteophytes and adequately decom- press this level as well. After sufficient decompression had been noted, the wound was again thoroughly irrigated, and a 6 large Smith and Nephew graft was impacted into position. Both grafts were in excellent position on both fluoroscopic views.

A 41 mm two-segment anterior cervical plate was chosen and positioned across the levels of C and C Four screws were placed with standard technique, affixing the plate well.

Its position was confirmed with the fluoroscope. The wound was thoroughly irrigated, and some remaining platelet concentrate was sprinkled in the wound. Excellent hemos- tasis was noted. The deep cervical fascia was reapproximated with several Vicryl interrupted stitches. The platysma was reap- proximated using a Vicryl interrupted stitch.

The subcutane- ous tissue was closed with Vicryl interrupted stitch. The skin was reapproximated using a running subcuticular Monocryl. The Miami J-collar was then placed, and the patient was awakened and extubated and brought to the recov- ery room in stable condition, with no immediate complications. Chapter 23 Vertebroplasty Hamdi G. Prepping and draping of the back. Inject local anesthetic.

Under fluoroscopic guidance, advance needle through skin and subcutaneous tissue, aiming for the pedicle of the desired vertebrae. Advance the needle through the pedicle into the mid ver- tebral body. Inject desired solutions, followed by methyl methacrylate. Monitor patient for any neurological symptoms. Description of Operation: The patient was identified and the site of surgery confirmed.

The patient was positioned in the prone position, with all bony prominences padded. The lower back was prepped and draped in the usual sterile fashion. Local anesthetic was applied over the posterolateral access sites. The patient then underwent vertebroplasty procedure utilizing surgical methyl methacrylate mixed with sterile barium powder for better opacification. Direct fluoroscopy was utilized during the cement injection.

The vertebroplasty was performed without difficulty and the needle was subsequently removed. The patient was kept in the prone position for 10 min to allow the cement to harden.

The patient did not complain of any significant back pain following the procedure and was neurologically intact. Postprocedure Care For the first 24 h after vertebroplasty, bed rest is usually recom- mended.

Activities may be increased gradually and most regular medica- tions can be resumed. There may be some soreness for a few days at the puncture site which may be relieved with an ice pack.

After that weakness of the deltoid and the biceps brachii muscles may develop. This palsy is motor-dominant. If there is a nar- row canal at the C2 level, this level should be included. If an insta- bility is recognized preoperatively, bone grafting for stabilization should be used instead of an HA spacer. In cases of a second operation, the neutral position is better than the extension position so that an airtome can be used instead of a T-saw for splitting of the spinous process.

Cervical alignment should be reconfirmed by x-ray before making the skin incision. Skin Incision: The midline incision is usually made from the C2 spinous process to the T1 spinous process. The ligament nuchae is dissected in midline. Exposure of the Laminae: The paravertebral muscle is detached from the lamina using an electric cautery, Cobb elevator, and scissors.

The semispinal muscles inserted to the C2 lamina are detached bilaterally, making a landmark. The posterior spines from the distal C2 to the proximal T1 are exposed. Each facet is also exposed without injury of the capsule. The edge of each spinous process is cut, and the long spinous process of the C6 and C7 are cut without a fracture of the lamina. The interlaminal soft tissues from the C2-C3 to the C7-T1 are removed with a rongeur and each yellow ligament is exposed.

Median Splitting of the Spinal Process: The epidural space at C is exposed with removal of the yellow ligament by an air drill and Kerrison rongeur. A cervical intervertebral spreader is useful for exposure of the epidural space at C7-T1. After spreading of the C7-T1 interlaminar space, the median split of the yellow liga- ment can be found.

The yellow ligament is easily removed from this split. The dural membrane is confirmed. The length of the epidural tube is measured from C7-T1 to C A T-saw with 0.

The T-saw runs in the epi- dural space from C3 to C7. Maintaining cervical lordosis with a lordotic keeper, median splitting of the processes is started from C3 to C7. To avoid generating heat when cutting the bone, physi- ological saline solution is sprinkled simultaneously. Median split- ting is achieved within several minutes. If it is difficult to insert the epidural tube, because of, for example, a severe stenosis, the narrowest interlaminal space should be carefully opened with the same procedure at C7-T1.

Median splitting should be separately carried out. If the T-saw is not available, using the thin Kerrison rongeur is recommended to split the remaining spinous processes one by one following the construction of the bilateral gutter. Constructing the Bilateral Hinge: The line of the lateral gutter is located at the transitional area between the lamina and articular process.

Using an air drill with a 4 mm round diamond bur, the outer cortex is cut and thinned. From the cephalad to the caudal direction, each lamina is opened bilaterally with a small curet. Confirmation of the Decompression: Adhesion between the dura and the yellow ligament is carefully detached with a small elevator.

If possible, posterior migration of the spinal cord should be confirmed with an intraoperative ultrasound sonography. Stabilization of the Hydroxyapatite Spacer: Three-sized spacer trial , , and mm length is done to determine the width of the spacer.

This spacer has small flanges to prevent displacement. A mm spacer is usually used at C3 or C4 and a mm spacer at the lower level. A bilateral bone tunnel for thread suture is made with a 2-mm round diamond bur. A spacer is tightly fixed between the split lamina with two nonabsorbable thread sutures. In case of cervical instability, an iliac bone graft is used for the unstable segment instead of an HA spacer, and bone chips are placed on the bilateral gutter.

Reattachment of the Semispinal Muscle:The semispinal cer- vical muscles are securely reattached to the spinous process of the axis bilaterally. This procedure prevents a postoperative malalign- ment of the cervical spine, especially kyphotic change. Closure: A suction drainage tube is placed on the laminae and the wound is closed layer by layer.

Postoperative lateral x-ray shows normal sagittal alignment. CT scan shows adequate spinal decompression. A too-tight thread suture may destroy the lateral gutter.

Postoperative Care: A suction drainage tube is removed within 24 h. Sitting and walking is permitted with a Philadelphia collar for 2 weeks. Early muscle exercises are recommended to maintain ROM of the neck. Details including positioning, surgical time out, operative techniques, and wound closures are described to familiarize the reader with both the fundamentals and nuances of each procedure.

The book gives a concise stepwise description of the main operations in urologic surgery, written in a standardized fashion using the most up to date and trusted resources. JOHN A. E-Book Description. Operative Dictations in Urologic Surgery 1st Edition PDF Free Download Operative Dictations in Urology offers practicing and trainee urologists succinct and precise operative dictations for wide range of both common and unusual urologic procedures.

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