Attending Physician: Dr. Mohana Rao Patibandla, M. Ch (NIMS), FESBSS (KIMS), FAANS (USA), FMINS (OSU, USA), FEVNS (UVA, USA), FPNS (UCD, USA), FNOSRS (UVA, USA).
Patient Information:
Patient’s Name: Devineni Srinivasa Rao
Patient’s Age: 54 years
Patient’s Gender: Male
Primary Diagnosis:
- Cervical compressive myelopathy
- Lumbar canal stenosis
Secondary Diagnosis:
- Diabetes mellitus (Newly diagnosed)
- Hypertension
Surgical Treatment:
- Moderate compression of the cord, especially on the right side at the cervical level, dealt with C5/6, C6/7 discectomy, and ACDF with Atlantis plating system.
- Extensive compression of the Lumbar nerve roots at L4/5, L5/S1, treated with lumbar canal decompression and Longitude system from L3 to S1.
Case Overview:
The patient presented to Dr. Rao’s Hospital, one of the best neurology hospital in Andhra Pradesh, with severe neck pain radiating to the left upper limb, excruciating pain, and inability to walk 100 meters.
Dr. Mohana Rao, a highly-qualified and experienced neurosurgeon in Guntur, Andhra Pradesh, examined the patient and ordered specific imaging tests. The patient was diagnosed with cervical compressive myelopathy and lumbar canal stenosis.
The compression of the spinal cord in the neck causes cervical myelopathy (cervical area of the spine). Poor motor skills, neck pain or stiffness, loss of balance, and difficulty walking are all symptoms of cervical myelopathy.
The spinal cord is a collection of nerves that flows through a tube formed by the vertebrae. The tunnel is known as the spinal canal. Stenosis, or narrowing of the spinal canal, can compress the spinal cord or the nerves that run from the spinal cord to the muscles. A spinal canal narrowing in the lower region of the back is known as lumbar spinal stenosis.
The patient was admitted through the emergency suite and brought back to the operating room, where the discectomy and lumbar canal decompression procedures were performed.
Primary Surgeon: Dr. Mohana Rao Patibandla, M. Ch (NIMS), FESBSS (KIMS), FAANS (USA), FMINS (OSU, USA), FEVNS (UVA, USA), FPNS (UCD, USA), FNOSRS (UVA, USA).
Surgery: 1. ACDF – C5/6 and C6/7 discectomy with Medtronic Titanium ACDF implants with two cornerstone cages.
Findings: The cord had moderate compression, especially on the right side at the cervical level, which was dealt with C5/6, C6/7 discectomy, and ACDF with Atlantis plating system. Bone strength was good, and the purchase of the screws was excellent.
Anesthesia: General; IV Fluid: 1500 ml LR; EBL: 400 ml; Specimens: None; Drains: None; Complications: None; Disposition: PACU; Condition: Stable
DOS: 12/02/2021
Procedure:
After identifying Mr. Srinivasa Rao in the preoperative holding area, the patient was taken to the operating room. He was transferred to an operating table in the supine position. The endotracheal intubation and general anesthesia were performed without difficulty.
Then, we placed a small shoulder roll underneath the patient’s shoulder to keep his neck slightly extended. We then tapped down the patient’s shoulders bilaterally to expose his lower cervical spine.
A fluoroscope was brought into the field to make sure that we could visualize the whole cervical spine area. Transverse incision medial to the right sternocleidomastoid muscle was marked at C5/C6 level. The surgical site was then prepped and draped in the usual sterile fashion.
A total of 20 mL of 0.25% ropivacaine with epinephrine was injected underneath the skin for local anesthesia and hemostasis. A #22 skin scalpel was used to incise the skin. Bovie cautery was used to divide the subcutaneous layer and platysma.
An avascular plane was then developed between the strap muscles of the neck medially and the sternocleidomastoid muscle and carotid sheath laterally. This was carried out down to the prevertebral fascia.
We then opened the prevertebral fascia with Metzenbaum. Kitner was used for sweeping the soft tissue away from the anterior cervical surface. We were able to identify the cervical vertebra bodies from C4 to C7 vertebral body levels.
A spinal needle was inserted into the C5-C6 disk space, and the cervical spine level was verified with an intraoperative fluoroscope. The microscope was then brought into the field, and further dissection and discectomy were performed under magnification.
A self-retaining retractor was placed into the deep space to open the surgical area. A 5 mm drill was used to flatten the anterior osteophyte and drilling of the bodies.
A #15-blade was used to incise the annulus fibrosis. The disk was emptied initially with drill and pituitary rongeur. High-speed bur was used to remove the osteophyte further. Forward angle curette was used to remove as many disks as possible. An M hook was then used to detach the residual posterior disk and PLL away from the vertebral body.
Kerrison punch was then used to remove the posterior part of the disk and annulus fibrosis and osteophytes. We then identified the plane between the PLL and the dura, and the Kerrison punch was then used to go bilaterally to remove the PLL and decompress the neural foramina.
The dural sac and bilateral neural foraminal were free from compression at the end of the decompression. SurgiFlo was then placed into the disk space to stop any bleeding. Two cornerstones 7 mm Medtronic cages were placed between the C5/6 and C6/7 vertebral bodies. Then, we established an appropriate plate over the C 5 to C7. The total procedure was under the biplane fluoroscopic spine suite.
Another intraoperative X-ray was taken, which demonstrated all of the screws in a good position. The surgical area was then irrigated with a copious amount of antibiotic solution. Adequate hemostasis was achieved with bipolar cautery.
The platysma was then closed with interrupted #3-0 Vicryl stitches. The subcutaneous layer was closed with interrupted #3-0 Vicryl stitches. The skin was closed with continuous #3-0 Monocryl. At the end of the procedure, all counts were correct.
Surgery: 2. Longitude system fixation from L3 to S1 with Lumbar canal decompression.
Findings: There was extensive compression of the Lumbar nerve roots at L4/5, L5/S1, treated with lumbar canal decompression and Longitude system from L3 to S1. There was the placement of Longitude Legacy Medtronic (6.5 x 45 mm x 6 screws; 6.5 x 40 mm x 2 screws) screws in the L3, L4, and L5, S1 bilateral pedicles.
Anesthesia: General, IV Fluid: 3000; EBL: 250 ml; Specimens: None; Drains: Romovac drain; Complications: None; Disposition: Room; Condition: Stable
DOS: 15/02/2021
Procedure:
After identifying in the preoperative area, the patient was brought to the operating room, where general anesthesia was induced, and endotracheal intubation was performed. Neuromonitoring leads were placed for SSEP, upper extremity reference, and lower extremity EMG. The patient was then positioned prone on chest rolls on the Biplane Cath Lab table. All pressure points were padded appropriately.
Biplane Cath Lab fluoroscopes were brought into the field and used to mark the midline and pedicles for the lumbar incision. This area was then prepped and draped in the usual sterile fashion.
A 22 # skin knife was used to incise the skin. Using a combination of biplane Cath lab and the different instruments, percutaneous longitude screws were placed in the pedicles of L3, L4, and L5, S1. Attention was first turned to the placement of pedicle screws. An awl under the guidance of a fluoroscope was used to create starting holes.
K wires were placed through the holes, and then a 5.5 mm tap from the Medtronic Longitude system was then used to tap each of the trajectories. Neuromonitoring was used for evidence of breaches with a pedicle stimulation probe. 6.5 x 45 mm screws were placed at all the levels as mentioned before bilaterally except in S1, where we placed 6.5 x 40 mm.
The screws were then stimulated, and there was no response of any screw at 20 microamps. Final lateral and AP fluoroscopy images demonstrated the screws in an adequate position. Two 120-mm titanium pre-contoured rods were placed on each side spanning from L3-S1. The locking caps were tightened to final torque now.
Final lateral and AP fluoroscopy images demonstrated the rods and screws that appeared in a good position. Then our attention was addressed towards the midline incision, and decompression as the significant portion of the compression was from the ligamentum of the flavum. His discs were bulged out, so L4/5 and L5/S1 were removed. We tried to remove as much ligamentum flavum and bone as possible to relieve his stenosis.
During this process, due to his long-standing nature of stenosis, there were adhesions with the dura, a small dural rupture, and CSF aggression was noted. It was sutured intraoperatively without any further leak. The wound was then irrigated with antibiotic solution.
The wound was then closed as follows. The muscle and fascia were closed with #0 Vicryl interrupted stitches. The subcutaneous layer was closed with 1-0 Vicryl stitches. The skin was closed with 2-0 Nylon and staples. There was no untoward complication during the surgery. Neuromonitoring showed suitable amplitudes at the end of surgery.
Date of Discharge: 17/02/2021
Post-operative Assessment:
Postoperatively, the patient recovered first in the post-anesthesia care unit and then the neurosurgical floor.
The recovery was uncomplicated following the first ACDF surgery. On 15/02/2021, we did the Lumbar surgery, following which the patient was extubated. He was able to walk without assistance on the 1st POD.
The patient was intentionally kept in the prone position as he had mild CSF leak secondary to longstanding dural calcification and leak during the surgery. There was a 100% absence of preoperative pain, but a very mild grip weakness in the left upper limb was developed.
The incision was clean, dry, and intact. The patient was having appropriate bowel movements and bladder function. Therefore, with pain well-controlled and actively taking p.o. intake, the patient was considered stable for discharge.
The patient was prescribed several medications, including pre & probiotics, calcium, and vitamin supplements. The sutures were removed after ten days of surgery.
Headaches, incision soreness, and pain are normal and expected after surgery. However, it should improve each day. The patient was given a prescription for pain medicine but may only need Ibuprofen or other NSAIDS to relieve any soreness.
Incision/Wound Care:
The dressing was applied over the incision following the surgery, which kept the area clean and dry. The patient was informed to avoid scrubbing, picking, or cleaning the incision and avoid applying creams or lotions, including antibiotics.
The patient was asked to apply a clean, sterile bandage on wounds with subcuticular sutures and steristrips. He was also requested to revisit for new dressing during the first seven days after surgery if previous ones become soiled or wet. There was no need for dressing over the incision after seven days.
The patient was told to keep the incision dry and inspect it daily. Use of creams or lotions, including antibiotics and hydrogen peroxide, to the site, was avoided. The patient was advised to notify Dr. Mohana Rao’s office immediately in case of drainage, swelling, redness of the incision, and/or a fever of 101 or greater.
Activity Instructions:
The patient was asked to stay calm and take it easy as the recovery would take time. Return to normal activities as tolerated. He was advised to avoid heavy lifting until the post-operative visit. Dr. Rao permitted the patient to resume work when he felt it was safe. This was usually 4 to 6 weeks after your surgery.
Follow-up Instructions:
The patient was asked to visit in a 2-week time for wound inspection, suture removal, and later in 6 weeks for follow-up.