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1 = Video Consent =
2
3 [[VA Form 10-3203 Fill.pdf>>url:https://www.va.gov/vaforms/medical/pdf/VA%20Form%2010-3203%20Fill.pdf]]
4
5 = Preop =
6
7 You will need lead, C arm, and C-armor for this case.
8
9 Ask the circulator to put 3 mL of epinephrine 1:100,000 per liter of three 3L normal saline bags for the irrigation.
10
11 Set the pump pressure to 50-60 to start. Always be aware of the diastolic blood pressure and keep the pump pressure below it.
12
13 Ask for a K wire off the field for marking.
14
15 = Room Setup =
16
17 The surgeon and scrub tech stand on the side of the pathology. Bovie generator and suction are at the foot of the bed. The endoscopic display, C-arm, and C-arm display are on the opposite side, in that order from head to foot.
18
19 [[image:1711072678730-474.png]]
20
21 [[image:https://attachments.office.net/owa/alattaraa%40upmc.edu/service.svc/s/GetAttachmentThumbnail?id=AQMkADkzZTgzMjU4LTBkN2YtNDZkOS04N2YxLWIwNWNhOGE1YmFkZgBGAAADfvFXFMm3NUOJ8dXu%2BtQfyQcALHAFTQ4NtUa%2BDtRuLX00RgAAAgEMAAAALHAFTQ4NtUa%2BDtRuLX00RgAEiJHsewAAAAESABAATJq1V4rBOEi17VXlCVGzjw%3D%3D&thumbnailType=2&token=eyJhbGciOiJSUzI1NiIsImtpZCI6IkU1RDJGMEY4REE5M0I2NzA5QzQzQTlFOEE2MTQzQzAzRDYyRjlBODAiLCJ0eXAiOiJKV1QiLCJ4NXQiOiI1ZEx3LU5xVHRuQ2NRNm5vcGhROEE5WXZtb0EifQ.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.OvfukViEPQa083g6DA4wfVl35OLyQCsUl_mrkFwyPWu8BQ2rxOdGgygNC0WCchUtjUsfESda0kRi7S8ackux9nrh0YoN5zySgZQFn3v2Ih2mpX-yg-ABIZkOEk625JnGair7mdfdP9F3DXCHHYA3H5J3IWIR_C8GdQ73bPfXai2mQGBbxAA-Lh82TLDfr4TN0jBJoIyKe0HX2C3rLBw6Rd5mPVYw2M_kyLV5EsC717dJv9S6Zag_1YKxAEU9-5hYkNS13gkytIo5Vfr3hRdiVgPfsni_r6GVt6kMeZDIp6cjiSx25KiQxLfu9Mi6HQg2cAP_9dd2Zwrr_sT7PDliSQ&X-OWA-CANARY=bdvoV-5s6qcAAAAAAAAAALBs8kIVStwYTCWpKrHiLNPV9OSo7OEkrkXk6DeuakqmU593NEMCRIQ.&owa=outlook.office.com&scriptVer=20240315003.06&clientId=BCA2708547B642B0AE50DF947A637CF8&animation=true||alt="Image preview" height="317" width="421"]][[image:https://attachments.office.net/owa/alattaraa%40upmc.edu/service.svc/s/GetAttachmentThumbnail?id=AQMkADkzZTgzMjU4LTBkN2YtNDZkOS04N2YxLWIwNWNhOGE1YmFkZgBGAAADfvFXFMm3NUOJ8dXu%2BtQfyQcALHAFTQ4NtUa%2BDtRuLX00RgAAAgEMAAAALHAFTQ4NtUa%2BDtRuLX00RgAEiJHsewAAAAESABAA0TY8mTKet06147MowhrbbQ%3D%3D&thumbnailType=2&token=eyJhbGciOiJSUzI1NiIsImtpZCI6IkU1RDJGMEY4REE5M0I2NzA5QzQzQTlFOEE2MTQzQzAzRDYyRjlBODAiLCJ0eXAiOiJKV1QiLCJ4NXQiOiI1ZEx3LU5xVHRuQ2NRNm5vcGhROEE5WXZtb0EifQ.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.AFYYHdphagH_zmyCZvmGpgS1hOAzgCwJTrJfy958n2MtzSpgFmnGe6jXazmqHaHDkndfQLhi8njlORjp3poZJNw8enQ8F-oAIWlFAE6FvsPLxCW1kGxEuQvCjhlV87iuUYVJSRtjjWCjyGCE0J6eE5bxWi4ckxb1BM2E5EIfUAJR_yFpEl0Q-hegIbh2O8aiNhGoiyS8NYdbk12Oe9P15_d-tOMskrxGze0VoCmUJmeirxTQgmJas_7QX0onjS9_quHAEWAabEydWnQN5CH2aJ1DMKMnl0hVH9s_ebElrOCgMH1iGDJV183UNf2Yj0ewbC4a0H3DMfbK5dmTAu7jOQ&X-OWA-CANARY=bdvoV-5s6qcAAAAAAAAAAIBzECkVStwYUk_PZKyUUnkrA0LtAVwMnTXNQ3hmhbTqvJZdnc2jAgY.&owa=outlook.office.com&scriptVer=20240315003.06&clientId=BCA2708547B642B0AE50DF947A637CF8&animation=true||alt="Image preview" height="316" width="420"]]
22
23 = Positioning =
24
25 Positioning is prone. Ideally, you would use a regular bed with a Wilson frame. [[image:https://cdn1.iconfinder.com/data/icons/surgical-surgery-operation-positions/324/surgery-operation-surgical-positions-patient-012-512.png||alt="Facing down, operation, patient, positions, surgery, surgical, wilson frame icon - Download on Iconfinder" height="129" width="129"]]
26
27 If no Wilson frame is available, you can use a regular bed with gel rolls. For skinny patients, the gel rolls are oriented vertically, parallel with the axis of the bed. For heavier patients, the gel rolls are oriented horizontally, one just below the sternal notch and the other just below the iliac crests.
28
29 Arms on arm boards, as high up as they will go.
30
31 = Marking =
32
33 Start with an AP shot, mark midline.
34
35 [[image:1711067645033-444.png||height="299" width="353"]][[image:1711067728824-787.png||height="298" width="326"]]
36
37 Adjust C arm so the end plates are sharp and the pedicles of the caudal vertebral body are aligned with the superior end plate. Then, use the K wire to mark a line intersecting the caudal margin of the ipsilateral pedicle of the superior vertebra and the rostral margin of the contralateral pedicle of the inferior vertebra.
38
39 [[image:1711074150016-619.png]][[image:1711073568575-745.png||height="334" width="355"]]
40
41 Go to a lateral. Make sure the pedicles and end plates are sharp. Mark the level of the appropriate disc space.
42
43 [[image:1711074191280-344.png||height="303" width="368"]][[image:1711074222691-701.png||height="299" width="319"]]
44
45 Mark the lateral projection of the tips of the spinous processes.
46
47 [[image:1711074823313-333.png||height="289" width="448"]][[image:1711074762191-924.png||height="289" width="394"]]
48
49 Mark a point midway between the lateral extensions of the axially-oriented lines, a few centimeters medial to the spinous process mark.
50
51 [[image:1711075243219-295.png||height="298" width="434"]]
52
53 = Draping =
54
55 This is not the same as usual spine draping.
56
57 1. Four blue towels in a square
58 1. Block drapes
59 1. Ioban
60 1. C armor
61 1. Open C armor and have an assistant hold it out during next step
62 1. Place "liver drape" which is basically a rectangle of ioban with raised edges that will collect irrigant and drain to the suction
63 1. Close C armor on top of liver drape
64 1. Endoscope, light source cable, and irrigation cable go off the top. Create a loop in all three and secure to the drape with an Allis clamp.
65 1. Drill and bipolar go off the bottom.
66
67 [[image:1711077188547-668.png]]
68
69 = Procedure =
70
71 Use 1% lidocaine with epinephrine 1:100,000 to raise a wheal at the marked entry point.
72
73 Use an 11 blade to incise the skin, then push the blade along the planned trajectory through the fascia.
74
75 Under AP fluoroscopy, advance a long spinal needle (or long Jamshidi if available) to the lateral aspect of the superior articulating process of the caudal vertebra.
76
77 [[image:1711076109913-428.png||height="389" width="409"]]
78
79 Switch to a lateral and make sure the needle is at the junction of the superior articulating process and pedicle of the caudal vertebra. Gently tap the needle with a mallet until it is lodged in the bone.
80
81 [[image:1711076419710-741.png]]
82
83 Place a wire through the bore of the spinal needle, then withdraw the needle. Pass serial dilators over the wire.
84
85 If you are doing a trans-SAP approach, you may consider using the trephines to resect part of the SAP.  Rotate the trephine counterclockwise in its approach to the spine, this helps it get through the fascia. Once against the bone, rotate clockwise to cut. Never allow the tip of the trephine to pass the medial pedicle line.
86
87 **Use a pusher tool to push the bone plug out of the tip of the trephine before withdrawing it.** Otherwise, it will pull out the wire and dilators and you will have to start over.
88
89 [[image:1711076837677-456.png]]
90
91 Pass the endoscope sheath over the largest dilator with the bevel pointed ventrally such that the tip docks against the superior articulating process. Then, bring the scope in.
92
93
94 To verify that you are against the pedicle, place a Kerrison in the foramen and hook the foot plate around the pedicle, then take an AP shot.
95
96 [[image:1711077123185-397.png]]
97
98 = Closure =
99
100 4-0 Monocryl single subcuticular stitch in the skin. Steri strip. No glue.
101
102 (% class="box infomessage" %)
103 (((
104 DATE OF SURGERY:
105
106 SURGEON: Dr.
107
108 ASSISTANT: Dr.
109
110
111 PREOPERATIVE DIAGNOSIS: ~*~** disc herniation
112
113 POSTOPERATIVE DIAGNOSIS: ~*~** disc herniation
114
115
116 PROCEDURE PERFORMED:
117
118 ~1. ~*~** endoscopic microdiscectomy
119
120
121 ANESTHESIA: GETA
122
123 ESTIMATED BLOOD LOSS: 20 ccs
124
125 FINDINGS: ~*~** disc herniation
126
127 DRAINS: none
128
129 COMPLICATIONS: none
130
131 DISPOSITION: stable to PACU
132
133
134 INDICATIONS FOR PROCEDURE
135
136 HISTORY: Patient is a ~*~** who presented with ~*~**
137
138 DIAGNOSTIC STUDY: MRI demonstrated ~*~** disc herniation
139
140 SURGICAL RISKS: The patient was well apprised of all objectives, benefits,
141
142 risks, and potential complications of the procedure, including but not limited
143
144 to: worsening of current status, the possible need for further procedures, the
145
146 risk of infection, headaches, CSF leak, possible spinal nerve injury resulting
147
148 in paralysis, infection, injury to major vessels causing hemorrhage, stroke,
149
150 loss of language function, coma and even death. No assurance was given whether
151
152 symptoms would improve following the procedure. Informed consent was obtained and
153
154 secured in the chart after the patient voiced understanding of these risks
155
156 and decided to proceed with the operation.
157
158
159 DESCRIPTION OF THE PROCEDURE
160
161 The patient was transferred to the operating room. He was given preoperative
162
163 prophylactic IV antibiotics.
164
165
166 ANESTHESIA: The patient was sedated and intubated without difficulty by the
167
168 anesthesia service. Eyes were taped shut after ointment was applied to prevent
169
170 corneal abrasion. A Bair Hugger was placed to maintain control of core body
171
172 temperature. A Foley catheter was inserted.
173
174
175 POSITIONING: The patient was turned prone on gel rolls. All pressure points were
176
177 padded.
178
179
180 OPERATIVE TECHNIQUE:
181
182 The patient was prepped and draped in the standard sterile fashion. The C arm
183
184 fluoroscopy was draped and brought into the operative field and the ~*~** level
185
186 was identified. The level of the spinous processes was marked on the skin on a
187
188 lateral shot. The entry point was marked about 2 cm medial to this mark along
189
190 the lateral projection of the ~*~** disc level.
191
192
193 A small skin incision was made
194
195 with an 11 blade. A spinal needle was introduced into the incision and passed
196
197 under fluoroscopic guidance to the junction of the lateral ~*~** pedicle and ~*~**
198
199 superior articulating process. A K wire was passed down the bore of the spinal
200
201 needle which was then removed. Positioning was verified on fluoroscopy before
202
203 passing serial dilators down the K wire. An 11 blade was passed in parallel to
204
205 the dilators to enlarge the fascial opening. The endoscopic instrument sheath
206
207 was passed over the dilators then the dilators and K wire were removed. Again,
208
209 appropriate positioning was verified by fluoroscopy.
210
211
212 The endoscope was
213
214 introduced through the sheath and continuous irrigation started at 60 mmHg. Care
215
216 was taken to keep the irrigation pressure below diastolic blood pressure. The
217
218 radiofrequency probe was used to dissect soft tissue from the superior
219
220 articulating process and ~*~** pedicle. The foramen was identified ventral to the
221
222 SAP and rostral to the ~*~** pedicle. Several large fragments of herniated disc
223
224 were removed from the foramen and ventral epidural space. The traversing ~*~**
225
226 nerve root was identified and was pulsating freely at the end of the case.
227
228 Bleeding was controlled with a combination of radiofrequency probe and
229
230 irrigation. After removal of the disc fragments the cavity was inspected and no
231
232 residual fragments were identified. The endoscope and sheath were withdrawn as a
233
234 single unit and the walls of the tract inspected for bleeding. Areas of bleeding
235
236 were cauterized with the radiofrequency probe.
237
238
239 The subcutaneous tissue was closed with 3-0 Vicryl suture. The skin was closed
240
241 with 4-0 Monocryl monofilament absorbable suture. Skin glue was placed over
242
243 the incision and a Primapore dressing was placed on top.
244
245
246 All sponge counts, needle counts and instrument counts were correct at the end
247
248 of the case. The patient tolerated the procedure well, without any complications and
249
250 was transferred in stable condition to the recovery room. Dr. ~*~** was
251
252 present during the critical portions of the case.
253 )))