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Posterior Cevical Laminectomy C3 through C7 with fusion/rods/screws from C3 through T2. Staples were out on 02/07/2012 and have followup with NS on March 1st... Still concerned about right arm weakness that showed up postop. I appreciated ant input as to the reports below.... Thank you so very much to you all!!!


Procedure Report CHITOWN2012
Result Type: Procedure Report
Result Date: 01 February 2012 0:00
Result Status: Unauthenticated
Result Title: Procedure Report
Performed By: Contributor_system, SOFTMED on 01 February 2012 0:00
Encounter info: Inpatient, 2/1/2012 - 2/9/2012
Procedure Report
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*The following report is provisional, pending final review by the physician*
****************************************************************************
PROCEDURE REPORT DATE: 02/01/2012
NAME: CHITOWN2012 HOSPITAL #:
PHYSICIAN: BILLING #:
PAT. TYPE: I PATIENT LOC
ADMIT DATE: 02/01/2012 DISCH DATE:

PREOPERATIVE DIAGNOSIS: Cervical spondylotic myelopathy.

POSTOPERATIVE DIAGNOSIS: Cervical spondylotic myelopathy.

OPERATIVE PROCEDURES: CERVICAL LAMINECTOMY C3 THROUGH C7, POSTERIOR SPINAL FUSION C3 TO T2, ARTHRODESIS AND SEGMENTAL FIXATION OF C3, C4, C5, C6, C7, T1, T2, DECOMPRESSION OF SPINAL CORD, USE OF BONE MORPHOGENETIC PROTEIN, AUTOGRAFT, ALLOGRAFT, NEURO MONITORING, C-ARM, STEALTH.

INDIVIDUAL CONSIDERATIONS: None. PREPARATION: Routine.

INDICATIONS: Patient is a 54-year-old right-handed gentleman with
several-month history of left upper extremity pain and weakness. Imaging studies revealed the presence of multilevel spondylosis causing significant spinal cord compression. Risks and benefits of performing a decompression and stabilization were discussed with the patient. After all questions were answered, consent for surgery was obtained. Because we were working in proximity to neural elements, neuro monitoring was utilized.
PROCEDURE: The patient was brought to the operating room and, after uneventful administration of general anesthesia; he was positioned on the Jackson table in a prone manner. All pressure points were padded and secured. Head was held in 3-point fixation via the Mayfield head holder.
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The dorsal cervicothoracic area was shaved, prepped and draped in usual sterile fashion. Following infiltration of local anesthetic, a midline skin incision was created. Using the Bovie, we performed subperiosteal dissection of the paraspinous musculature. AP intraoperative radiograph was obtained verifying our level. As such, we optimally exposed from C3 down to T2. Care was taken not disrupt C2-3 or T2-T3. We then, following optimal exposure of the spinal column, drilled the lateral muscles for C3 through C7. A starting point approximately 1 mm medial to the center of the joint was selected and trajectory of 30 degrees cephalad, 30 degrees lateral was drilled. These holes were probed, tapped, probed again prior to placement of the right sized screw which was 3.5 x 12. We used a Midas Rex to demarcate the starting point for thoracic pedicle screws and, using a Lenke, we accessed pedicle down to 20, probing before accessing again down to 30 mm. As such, these holes were probed, tapped and probed again prior to placement of the right sized screw as determined by the Stealth. We now performed our laminectomy by drilling two vertical troughs at the laminar facette junction. Using a nerve hook, we developed an epidural plane and then carefully took down the osteal ligamentous structures of left and right sides as well as superiorly and inferiorly. As such, with doing this we were able to remove the lamina en bloc. We were now able to use the nerve hook to palpate the underside of the remaining lamina and facette edges. We now used a combination of Kerrisons to remove this last bit of bone circumferentially. Following this, irrigation of the wound was performed, arthrodesis of all bony surfaces was performed, BMP sponges were packed in the facette joints bilaterally. Two rods were cut, contoured and secured by means of blockers. We then put the rest of the autograft and allograft over all exposed bony surfaces. The rods were secured by means of blockers. In addition, a crosslink was placed. Radiograph showed good placement of all screws and rods. Accordingly final tightening of all blockers was performed, 0.25% Marcaine plain was used for infiltration of the muscles. Two drains were placed in the wound and made to exit out a separate stab skin incision. Closure was undertaken by means of 0, 2-0, 3-0 Vicryl followed by staples on the skin. At the end of procedure, all needle and sponge counts were correct. The patient was transported to recovery room without incident. Of note, all neural monitoring was stable as well.
Unreviewed
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Completed Action List:
* Perform by Contributor_system, SOFTMED on 01 February 2012 0:00
* Transcribe by Contributor_system, SOFTMED on 01 February 2012 0:00
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* Final Report *
Result Type: XR Spine Cervical (AP/Lateral)
Result Date: 02 February 2012 12:21
Result Status: Authenticated
Result Title: XR Spine Cervical (AP/Lateral)
Performed By: on 02 February 2012 13:53
Verified By: on 02 February 2012 13:53
Encounter info: Inpatient, 2/1/2012 - 2/9/2012
* Final Report *
Reason For Exam s/p fusion
Report
XR Spine Cervical (AP/Lateral) 2/2/2012 12:05 PM
Cl to (27) can be seen on the lateral view. There has been posterior surgical fusion
from C3 to T2 held in place with 2 rods and multiple screws. A laminectomy defect
is noted from C3 to C7. Bony graft is seen between the transverse processes at least from C4 to T1 bilaterally. Surgical skin clips are present in the midline over the cervical and upper thoracic spine. The prevertebral soft tissues are normal. There is straightening of the normal lordotic curve of the cervical spine.
IMPRESSION:
POSTERIOR SURGICAL FUSION FROM C3 TO T2
Signature Line
***Final Report***
Attending Radiologist:
Date Signed Off: 02/02/2012 13:53 Transc. by: TR 02/02/2012 13:53
Dictated by: 02/02/2012 13:53
Completed Action List:
* Order by on 01 February 2012 14:31
* Perform by on 02 February 2012 12:21
* VERIFY by on 02 February 2012 13:53
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* Final Report *
Result Type: MR Spine Cervical WWO Contrast
Result Date: 07 February 2012 21:43
Result Status: Authenticated
Result Title: MR Spine Cervical WWO Contrast
Encounter info: Inpatient, 2/1/2012 - 2/9/2012
* Final Report *
Reason For Exam WEAKNESS

Report

PROCEDURE: MR Spine Cervical WWO Contrast

HISTORY: Status-post posterior spinal fusion. Weakness. Evaluate for myelopathy.

TECHNIQUE: Pre-infusion T1 and T2 weighted spin echo, STIR, and post-infusion T1 weighted images were obtained.

COMPARISON: MR cervical spine, 10/18/11

FINDINGS: Postsurgical changes status post C3 to T2 posterior spinal fusion are identified. Laminectomies are seen from C4 through C7. Metal artifact from the hardware limits evaluation of the adjacent structures. A fluid collection is seen spanning the laminectomy defects, most pronounced from C7 through T2 and extending to the subcutaneous tissues.
There is mild residual narrowing at the C3 vertebral body level. The ill-defined T2/STIR hyperintense cord signal at this level likely represents artifact from adjacent hardware. Evaluation for cord signal abnormality is limited secondary to metal artifact; however, no definitive abnormality is identified. Additionally, the known myelomalacia at C5-6 is not well seen.
There is straightening of the normal cervical lordosis. The alignment is unremarkable. The vertebral body heights are well-maintained. Mild loss of intervertebral disk height is seen at C3-4, C5-6, and C7-T1.
The atlanto-occipital and atlantoaxial joints are unremarkable. Mild endplate degenerative changes are seen at C3-4 and C5-6.
C2-3: There is no significant central spinal canal or foraminal stenosis.
C3-4: There is a small posterior disk/osteophyte complex and moderate right and mild left uncovertebral hypertrophy resulting in mild central spinal canal stenosis. There is moderate right and mild left foraminal stenosis.
C4-5: There is moderate right facet hypertrophy, resulting in moderate right

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* Final Report *
foraminal stenosis. There is no significant central spinal canal or left foraminal stenosis.
C5-6: There is a broad-based posterior disk/osteophyte complex and moderate bilateral uncovertebral hypertrophy, without significant central spinal canal stenosis. There is mild left foraminal stenosis. There is no significant right foraminal stenosis.
C6-7: Evaluation is limited by the metal artifact.
C7-T1: There is no significant central spinal canal or foraminal stenosis.

IMPRESSION:
1. Status post C3 to T2 posterior spinal fusion. Postoperative fluid is seen spanning the surgical bed.
2. Residual narrowing at the C3 vertebral body level. Ill-defined T2/STIR hyperintense cord signal at this level likely is felt to likely represent artifact from adjacent hardware, but recommend correlation with associated weakness.
3. Please refer to the CT cervical spine performed on the same day for further characterization.
Signature Line
***Final Report***
THE ATTENDING RADIOLOGIST INTERPRETED THIS STUDY WITH THE RESIDENT
WHOSE NAME APPEARS BELOW, AND FULLY AGREES WITH THE REPORT
AND HAS AMENDED THE REPORT WHEN NECESSARY:
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* Final Report *
Result Type: CT Spine Cervical WO Contrast
Result Date: 08 February 2012 8:28
Result Status: Authenticated
Result Title: CT Spine Cervical WO Contrast
Performed By:
Verified By:
Encounter info: Inpatient, 2/1/2012 - 2/9/2012
* Final Report *
Reason For Exam eval postop construct
Report
PROCEDURE: CT Spine Cervical WO Contrast

INDICATION: Evaluate postoperative construction. Cervical myelopathy. According to the electronic medical record, the patient is status post cervical laminectomies from C3 through C7, posterior spinal fusion from C3 through T2 with instrumentation and graft material, on 2/1/2012.

TECHNIQUE: CT cervical spine, without contrast. Coronal and sagittal reconstructions.

COMPARISON: Numerous prior studies, most recently the MRI cervical spine from 2/7/2012 and the CT cervical spine from 1/17/2012, as well as the intraoperative spine plain films from 2/1/2012.

FINDINGS: Postoperative changes are identified status post decompressive laminectomies from C3 through C7 and posterior spinal fusion from C3 through T2. The posterior spinal instrumentation includes bilateral lateral mass screws at each level from C3 through T2. A horizontal cross bar is identified at the C6 level. Metallic streak artifact related to the instrumentation degrades the surrounding detail. The right C7 pedicle screw extends inferiorly into the right C7-T1 facet joint (series 5, image 54). No evidence of hardware fracture or failure is identified. Bone graft material surrounding the lower aspect of the posterior spinal fusion, inferiorly as far as the T3 level, has been lifted away from the osseous structures on the basis of an underlying fluid collection that extends from the lower aspect of the decompressive laminectomy surgical bed (series 2, image 103; series 5b, image 45). Within the limits of CT, the dominant portion of this collection measures approximately 2.9-cm (AP) x 1.6-cm (TV) x 6.8-cm (CC), at the T2-3 level. Additional, smaller areas of fluid are identified extending more superficially to the skin. These collections are also demonstrated in the MRI cervical spine from 2/7/2012. Please see the report of that study for further details. Numerous gas foci are also identified along the surgical bed.
Straightening of the normal cervical lordosis is noted with slight focal reversal centered at the C4-5 level. The alignment and vertebral body heights are normal.
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" Final Report *
Sclerosis along the endplates at the C3-4, C5-6 and 07-Ti levels most likely corresponds to discogenic degenerative change. No acute fracture is identified.
Multilevel degenerative disk disease is identified on the basis of posterior disk osteophyte complexes, decreased disk heights and vacuum disk phenomenon, most prominent at the C3-4, C5-6 and C7-T1 levels.
At the C2-3 level, there is a mild posterior disk osteophyte complex, bilateral uncovertebral and facet arthrosis, without resulting in significant central canal stenosis or neural foraminal narrowing.
At the C3-4 level, there are postoperative decompressive changes, moderate posterior disk osteophyte complex, bilateral uncovertebral and facet arthrosis, resulting in moderate right and mild left neural foraminal narrowing.
At the 04-5 level, there are postoperative decompressive changes, mild posterior disk osteophyte complex, severe right uncovertebral and facet arthrosis and mild left uncovertebral and facet arthrosis, resulting in severe right and no left neural foraminal narrowing.
At the C5-6 level, there are postoperative decompressive changes, severe bilateral uncovertebral arthrosis and mild bilateral facet arthrosis, together resulting in severe left and mild right neural foraminal narrowing.
At the C6-7 level, there are postoperative decompressive changes, a moderate posterior disk osteophyte complex, bilateral uncovertebral and facet arthrosis, resulting in stable severe right and moderate left neural foraminal narrowing.
At the C7-T1 level, there are postoperative decompressive changes, a moderate posterior disk osteophyte complex, resulting in moderate right and mild left neural foraminal narrowing.
Moderate right mastoid air cell opacification is noted.

IMPRESSION:
1.Postoperative changes status post decompressive laminectomies from C3 through C7 and posterior spinal fusion from C3 through T2, as described. No evidence of hardware fracture or failure.

2. Postoperative fluid collections along the surgical bed extend as far inferiorly as T3, with the dominant portion of the collection measuring 2.9 x 1.6 x 6.8-cm at the T2-3 level. The differential diagnosis for the fluid collections includes postoperative seroma, hematoma, cerebrospinal fluid, with the possibility of superinfection not excluded. Clinical correlation and follow-up, including with consideration for fluid sampling are suggested, as clinically warranted.

3. Please see the recent MRI cervical spine report from 2/7/2012 for further details.

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* Final Report *
Signature Line
***Final Report***
Attending Radiologist:
Date Signed Off: 02/08/2012 13:12 Transc. by: TR 02/08/2012 13:12
Dictated by: 02/08/2012 12:38
Completed Action List:
* Order by on 08 February 2012 6:44
* Perform by on 08 February 2012 8:28
* VERIFY by on 08 February 2012 13:12
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