The report below describes a patient undergoing spinal surgery. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed. nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn– Click Here to Submit Redacted Surgery Case Study –nnOPERATIVE REPORTnnDATE OF OPERATION: 06/XX/2020nnOPERATING SURGEON: A.K. M.D.nnPREOPERATIVE DIAGNOSES:nC4-5 subluxation with spinal cord compression.nC4-5 anterior cervical osteomyelitis and diskitis.nnPOSTOPERATIVE DIAGNOSES:nC4-5 subluxation with spinal cord compression.nC4-5 anterior cervical osteomyelitis and diskitis.nnOPERATION PERFORMED:nC4 and C5 posterior cervical decompression with resection of epidural phlegmon.nC4-C5 posterior cervical arthrodesis with allograft and autograft.nC4-5 posterior cervical instrumentation with lateral mass screws and rods.nnFIRST ASSISTANT: B. J., P.A.nnANESTHESIA: General.nnDESCRIPTION OF OPERATION: The patient was brought into the operating room. He was intubated. Appropriate lines were placed and he was placed into Mayfield head fixation. Using strict log roll precautions, he was then turned prone onto an OR table with gel rolls going across his chest and across the iliac crest. Arms were tucked after pressure points were padded and he was positioned with his neck in a neutral position slightly extended to try to counteract to the subluxation.nnImmediate C-arm imaging was obtained to ensure good positioning. The midline neck was now shaved, prepped, and draped and surgery was begun.nnIncision was marked out over the midline what was felt to be the C4 and C5 spinous processes. Incision was made and carried down through the subcutaneous tissues remaining in the median raphe until the spinous processes were identified.nnC-arm was brought back in to positively identify the C4 and C5 levels. We now continued exposure until we had exposed from inferior C3 to superior C6 encompassing the lateral masses bilaterally of C4 and C5. We first performed the instrumentation using a drill guide and drill with C-arm to guide angle of trajectory. Standard landmarks were used to place lateral mass screws, that is the lateral mass was bisected both in a rostral-caudal and left-right fashion and the entry point 1 mm inferior and lateral was chosen. We then angled approximately 5 to 10 degrees laterally. Rostrally, the angle for the screws was determined by the C-arm. 14 mm pilot hole was drilled and then sounded with a ball probe to make sure we had not perforated, following which the 14 mm polyaxial lateral mass screws were placed. This was done into the bilateral C4 and bilateral C5 lateral masses.nnWe now decorticated. The curette was used to curette out the facet at C4-5, both the inferior articulating facet of C4 and the superior articulating facet of C5 bilaterally. We additionally used the drill to drill the lateral lamina that remained after decompression and a combination of allograft and autograft, which had been harvested with the decompression, were used to fill the facet and do an onlay lateral laminar arthrodesis.nnPrior to the arthrodesis, the decompression was done. Leksell rongeur was used to remove the spinous process of C4 and C5 as well as the lamina, which was further removed with Kerrison rongeurs. The lamina was thinned using the high- speed drill and ligamentum flavum was also removed from the C3-4, C4-5, and C5-6 interspaces.nnOf note, there was an organized vascular collection, which was unusual to see at the level of C4-5. This may have been inflammatory reaction to the infection on the opposite side. Although no clear infection was seen, this phlegmon was adhesed to the dura and had to be removed as a separate piece. It was sent half of it to pathology and half of it to microbiology for evaluation. We also took cultures in this area.nnOnce the decompression was completed, arthrodesis was done as mentioned and finally, the instrumentation was completed by placing rods into the lateral mass screws, which were then affixed with set screws and final tightening done.nnWe now thoroughly irrigated. Bleeding was controlled with Floseal, bipolar, and Bovie as well as bone wax to the bleeding bone edges. Given the patient’s renal failure and cirrhosis and low starting hematocrit, we elected to place a drain, which was tunneled out a separate incision. Finally, the wound was closed in multiple layers, first closing the cervical fascia with interrupted 0 Vicryl sutures, placing some inverted 2-0 and 3-0 Vicryl sutures and then staples were applied to the skin. Wound was cleaned, dressed with Telfa, 4x4s, and Tegaderm. The patient then turned back supine, placed back into a C-collar, extubated, and sent to the recovery room. Estimated blood loss was 20 to 25 cc. Sponge and needle counts were correct. There were no complications.nnSPECIMEN SENT: Epidural phlegmon, half to pathology, half to microbiology and cultures were also obtained.
