Case -T12-1A OPERATIVE REPORT, LAMINECTOMY AND FORAMINOTOMY

Case
-T12-1A OPERATIVE REPORT, LAMINECTOMY AND FORAMINOTOMY
LOCATION: Inpatient, Hospital
PATIENT: Rebecca Sole
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
PREOPERATIVE DIAGNOSIS: Herniated disc, L4-5 on the left
POSTOPERATIVE DIAGNOSIS: Same-lumbar disc, L4-5 (fourth lumbar
vertebra-fifth) on the left
PROCEDURE PERFORMED: Laminectomy, foraminotomy, and removal
of disc
ANESTHESIA: General
PROCEDURE: Under general anesthesia, the patient was placed in the prone position. The back was prepped and draped in the usual manner. An incision was made in the skin, extending through subcutaneous tissue. Lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The interspace was localized via x-ray. A general laminotomy and foraminotomy were performed. We got onto the L4-5 interspace, saw the extruded disc, removed the fragments, entered the disc space, and cleaned out the disc space. There were fragments on the body of L5. There were fragments incarcerating the nerve root. I removed these, freed up the nerve root, took out all the disc fragments, and irrigated the wound well. Satisfied that I had decompressed the root well, I then put a Hemovac drain in the wound and closed the wound 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 PAR (postanesthesia recovery).
T12-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________