A Outpatient Evaluation and Management 1 Preop: obtain focused history and performs focused exam describe key physical exam maneuvers (anterior drawer test) concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests 2 Preop: Orders and interprets required diagnostic studies able to order and interpret essential imaging studes 3 Preop: Prescribes and manages nonoperative treatment identifies critical pathologic findings on imaging studies guides trial of medical managment attempts trial of physical therapy orders appropriate orthosis 4 Preop: Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Postop: 2-3 Week Postoperative Visit wound check diagnose and management of early complications<br /> 6 Postop: ~ 3 month Postoperative Visit diagnosis and management of late complications<br /> 7 Postop: 1 year Postoperative Visit C Preoperative H & P 1 Perform basic medical and orthopaedic history and physical identify medical co-morbidities that might impact surgical treatment 2 Screen medical studies to identify and contraindications for surgery 3 Ensure all studies are required to proceed with surgical intervention 4 Perform operative consent describe complications of surgery including death due to bleeding loss of kidney function due to ureter injury retrograde ejaculation due to injury to the hypogastric plexus sympathetic syndrome due to injury to the sympathetic chain pseudoarthrosis dural tear general orthopaedic complications including infection, blood loss requiring transfusion, rare orthopaedic complications including idiopathic nerve injury such as serratus palsy, ulnar nerve palsy, peroneal palsy.
E Preoperative Plan 1 Radiographic templating 2 Surgical walkthrough including desciption of basic anatomy, appropriate approach, and goals of therapeutic skills 3 Performs appropriate physical exam maneuvers under anesthesia 4 Description of potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation expandable cage anterior fixation (plate most common) 2 Room setup and Equipment radio-opaque operative table fluoroscopy MEP and SEPs 3 Patient Positioning place MEP, SEP, and EMG leads prior to transfer to operating table place Foley catheter transfer to radio-opaque operating table and place in right lateral decubitus position axillary roll was placed in the right axilla use beanbag to keep body at 45 degrees from horizontal flex hips and knee place pillows between legs, pad common peroneal nerve place tape over patient to keep him secure Flexed the table at the costal pelvic junction, G Anterior Retroperitoneal Approach 1 Identify 11th rib and lateral border of rectus abdominis draw oblique line connecting two dots. 2 Incise skin and subcutaneous fat make incision from posterior half of 11th rib to lateral border of rectus abdominis 3 Ressect 11th and 12th rib 4 Expose aponeurosis of external oblique muscle 5 Divide external oblique in line with fibers 6 Divide internal oblique in line with incision and perpendicular to muscle fibers 7 Divide transverus abdominis in line with skin incision H Deep Dissection 1 Bluntly disect plane between retroperitoneal fat and psoas fascia 2 Retract peritoneal cavity medially bring ureter with peritoneal cavity 3 Place Omni retractor retract diaphram superiorly ureter and kidney reflected away from the spine 4 Follow surface of psoas muscle to vertebral bodies 5 Identify disc space, insert needle, and take lateral radiograph to confirm level 6 Tie off segmental lumbar arteries of aorta of L2, L3, and L4 usually cut between silk sutures 7 Migrate aorta to contralateral side and away from plane of corpectomy I Perform L3 corpectomy 1 Perform L2/3 deskectomy clear L2 inferior endplate and inspect to make sure it is structurally viable 2 Perform L4/5 diskectomy clear L4 superior endplate and inspect to make sure it is structurally viable 3 Perform L3 corpectomy perform from anterolateral approach leave anterior L3 cortext to prevent anterior kickout of cage pay attention to integrity of posterior cortex J Decompress thecal sac (optional) 1 Identify foramina of L2- L3 and L4-5 and use them as a landmark care was taken to protect the nerve roots exiting the spine at each level K Insert cage 1 Identify lordotic angle of superior and inferior endplate this is critical to prevent anterior kickout due to lordosis of lumbar spine typically use a 15 deg lordotic inferiorly and a 5 deg lordotic end plate superiorly. 2 Assemble expandle cage or cut harms cage change will typically be between 30 and 40mm 3 Place autograft in cage and insert 4 Ensure compression/distraction fit 5 Bone graft was packed anteriorly and laterally 6 Obtain AP and lateral radiograph to confirm satisfactory position N Wound Closure 1 Ensure appropriate hemostasis 2 Remove Omni retractors The abdominal contents were placed back into their normal anatomic position. 3 Close muscular layers muscular layers of of transverus abdominis, internal oblique, and external oblique was then closed in layers with running #1 PDS suture. 4 The subcutaneous tissue was closed with a running #3-0 Vicryl suture. describe step 5 The skin was closed with subcuticular #3-0 Monocryl suture. 6 Steri-Strips were applied. Sterile dressing was applied.
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders 2 Appropriate wound care 3 Appropriately orders and interprets basic imaging studies 4 Orders appropriate inpatient occupational and physical therapy (weight-bearing, ROM, limitations of physical therapy) 5 Appropriate medical management and medical consultation 6 Discharges patient appropriately