Case -T12-2A RECORD OF OPERATION, LAMINOTOMY AND FORAMINOTOMY

Case
-T12-2A RECORD OF OPERATION, LAMINOTOMY AND FORAMINOTOMY
LOCATION: Inpatient, Hospital
PATIENT: Kenny Jetty
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
PREOPERATIVE DIAGNOSIS: Herniated disc, L4-5 (fourth lumbar vertebra-fifth) on the left
POSTOPERATIVE DIAGNOSIS: Herniated disc, L4-5 on the left
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of extruded disc
ANESTHESIA: General
PROCEDURE: Under general anesthesia, the patient was placed in a prone position, and the back was prepped and draped in the usual manner. An incision was made in the skin and extended through subcutaneous tissue. The lumbosacral fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The interspace was localized via x-ray. We then performed a generous laminotomy with the Kerrison rongeurs between L4-5. We did a partial facetectomy and got to the extruded disc by retracting on the nerve root. The disc had perforated through the annulus. We removed the disc material, entered the disc space, removed much degenerating material from the L4-5 interspace, went across the midline, and went laterally; I was satisfied I had decompressed the disc space well. I was able to pass a hockey stick down the foramen and across the midline. The wound was well irrigated. A Hemovac drain was placed into the wound. The wound was then closed in layers, utilizing double knotted 0 chromic on the lumbodorsal fascia with 0 Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to recovery.
PATHOLOGY REPORT LATER INDICATED: See T12-2B.
T12-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________