[Expert Solution]: Case 3: Fusion Preoperative diagnosis:…

Case 3: Fusion Preoperative diagnosis: Lumbar stenosis with neurogenic claudication, L4-5 spondylolisthesis; morbid obesity BMI 42 Postoperative diagnosis: Lumbar stenosis with neurogenic claudication, L4-.S spondylolisthesis; morbid obesity BMI 42 Procedure(s) performed: 1. L4-5 laminectomies with bilateral 1.4/5 foraminotomies 2. Left L4-5 transforaminal lumbar interbody fusion with placement of PEEK/carbon fiber cage + local bone autograft 3. Use of intervertebral cage x 1 4. Posterior instrumented spinal fusion, L4-5, with screws/rods (Depuy) + local bone autograft/5cc DBM putty (in posterolateral gutters) 5. Use and interpretation of intraoperative fluoroscopy 6. Use and interpretation of intraoperative neurophysiological monitoring including SSE? Is, free EMG Anesthesia: GETA EBL: 100cc Specimens: None Implants: bilateral L4/5 pedicle screws, 9 x 27mm TLIF cage, rods x 2 Drains: JP x 1 (subfascial) Complications: None Condition: Stable, extubated, to PACU Findings: 1. Severe stenosis at L4-5 2. Grade I spondylolisthesis at L4-5 -> – 75% reduction attained Preop indications: 75-year-old female who presents for chronic low back and radiating bilateral leg pain. Pain intensifying over time. Both sides involved pretty equally. She was referred by her doctor who was seeing her for epidural injections. Her last epidural steroid injection was in summer which didn’t give much relief. She has difficulty walking, standing, and driving. Her sciatica pain worsening. Walking tolerance has progressively diminished. She has tried physical therapy as well as Ibuprofen 600 mg with no benefit. Lumbar x-ray and MRI reviewed show mobile grade 1-2 spondylolisthesis at L4-5 and severe stenosis at L4-5. Clinical picture is consistent with progressive neurogenic claudication. She has exhausted non-operative treatments Including PT, medications, and epidural injections and has experienced progression in her symptoms. As such, we discussed surgery. Recommended surgery is L4-.5 TLIF with full decompression at L4-5, discussed at length the details of procedure. Recovery as well as postoperative care were discussed. Risk 2nd benefits as well as all alternative treatments were discussed. Procedure: Patient was brought to the operating room and placed in the supine position. After completion of all anesthesia-related activities, including induction of general endotracheal anesthesia and placement of appropriate lines, the patient was positioned prone on a Jackson frame. All bony prominences were well-padded. Intraoperative fluoroscopy was brought in in the lateral projection to localize the midline skin incision. I should note that there was significant reduction in the L4-5 spondylolisthesis with prone positioning on the Jackson frame. The skin of the low back was then prepped and draped in typical sterile fashion. Surgical timeout was performed, verifying the patient’s name, medical record number, and proposed procedure. Patient was administered 2 grams of Ancef preoperatively. ICD-10-CM codes: (4 codes) ICD-10-PCS codes: (5 codes) Condition: Stable, extubated, to PACU Findings: 1. Severe stenosis at 2. Grade I spondylolisthesis at L4-5 reduction attained Preop indications: 75 -year-old fenale who presents for chronic low back and radiating bilateral leg pain. Pain intensifying over time. Both sides involved pretty equally. She was referred by her doctor who was seeing her for epidural injections. Her last epidural steroid injection was in summer which didn’t give much relief. She has difficulty walking, standing, and driving. Her sciatica pain worsening. Walking tolerance has progressively diminished. She has tried physical therapy as well as Ibuprofen 600 mg with no benefit. L.umbar xray and MRI reviewed show mobile grade 1-2 spondylolisthesis at L4-5 and severe stenosis at L4-5. Clinical picture is consistent with progressive neurogenic claudication. She has exhausted non-operative treatments including PT, medications, and epidural injections and has experienced progression in her symptoms. As such, we discussed surgery. Recommended surgery 100 cc