A Outpatient Evaluation and Management 1 Obtains focused history and perform focused exam describe key physical exam maneuvers (lumbar nerve root function) concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests 2 Interpret basic imaging studies interpret biplanar films of the L-spine 3 Order and interprets advanced imaging studies myelogram CT MRI findings central stenosis foraminal stenosis identifies nerve root anatomy correlate clinical and imaging findings to form clinical diagnosis 4 Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for simple cases single level HNP with radiculopathy 5 Prescribes and manages nonoperative treatment medical management attempts medical management of lumbar radiculopathy (NSAIDs, gabapentin) orders appropriate diagnostic and therapuetic selective nerve root or epidural steroid injections attempts trial of physical therapy referrals to other physicians 6 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 7 Provides, modifies and adjusts procedure and patient specific post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check diagnose and management of early complications start formal outpatient physical therapy postop: ~ 3 month postoperative visit resume to full activity advance spine restrictions and activity levels diagnosis and management of late complications B Advanced Evaluation and Management 1 Provides complex non-operative treatment individualized care comprehensive informed consent shared decision making 2 Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for complex cases multilevel stenosis with deformity 3 Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for complex cases multi-level stenosis with deformity 4 Capable of surgically treating simple complications drainage of hematoma debridement of infection C Preoperative H & P 1 Neurologic Exam carefully documents neurological status of bilateral lower extremities strength, sensation, reflexes, and primary symptoms 2 Recognizes indications for and initiates immediate additional work-up ("Red Flags") or urgent surgical care progressive deficit cauda equina syndrome results from terminal spinal nerve root compression in the lumbosacral region considered one of the few true medical emergencies in orthopaedics key features bilateral leg pain bowel and bladder dysfunction saddle anesthesia lower extremity sensorimotor changes 3 Order basic imaging studies order bipolar radiographs of the L-spine review advanced imaging such as MRI look for specific findings such as spondylolisthesis, central/lateral recess/foraminal stenosis, and levels of involvement 4 Screen medical studies to identify and contraindications for surgery confirms no recent infection contraindicating surgery (UTI) 5 Perform operative consent documents failure of nonoperative measures such as physical therapy and epidural streoid injections describe complications of surgery including cauda equina syndrome recurrence iatragenic nerve root injury infection
E Preoperative Plan 1 Identifies area of decompression on preoperative imaging 2 Execute surgical walkthrough describe steps to the attending prior to the start of the case describe potential complications and list steps to avoid them F Room Preparation 1 Surgical instrumentation microscope or loupes microdiscectomy set 2 Room setup and equipment table standard radiolucent table with Wilson frame vs. Jackson spine flat top table C-arm c-arm perpendicular to table microscope (optional) microscope in from opposite side of C-arm 3 Patient positioning prone with arms at 90° max abduction and flexion to prevent axillary nerve injury foam padding on chest so that nipples are pointing midline straight down pads over ASIS and gel pads on knees bilateral TED hose and SCDs G Dissect to Spinous Process 1 Palpate anatomic landmarks identify the coccyx and the sacrum distally identify the spinous processes proximally palpate the iliac crests to identify the L4 vertebral level 2 Localize level of incision with anatomic or radiographic landmarks insert a spinal needle slightly off of the midline direct the spinal needle toward the disk of interest 3 Confirm disk level with fluoroscopy 4 Make midline incision. midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae) ~3-4cm in length for single level 5 Dissect subcutaneous tissue down to fascia insert a cerebellar retractors for fascial exposure 6 Incise the fascia make a vertical incision through the fascia on the side of the disk herniation cauterize lumbodorsal fascia over spinous processes to just lateral of midline H Clear Lamina 1 Subperiosteal dissection with Cobb along spinous processes 2 Subperiosteal dissection of lamina cranial to caudal down to lamina<br /> 3 Place probe under lamina to identify level radiographically 4 Use Cobb to strip laterally along lamina until facet capsules identified but not violated 5 Place deep retractors for better visualization I Laminotomy and Ligamentum Flavum Resection 1 Remove spinous processes of operative levels with rongeur bring in the microscope 2 Create working window use a size 2 angled curet to create a plane between the ligamentum flavum and lamina of the cephalad vertebra use a burr to thin the lamina then complete resection with Kerrison rongeurs the window should extend cephalad from the interspace to the level of the pars interarticularis of the superior vertebra and caudad from the interspace to the superior most 3 mm of the inferior lamina extend the laminotomy laterally to the medial edge of the facet joint complex take a 45 degree Kerrison punch and remove the remaining bone to complete the laminotomy 3 Begin decompression begin with decompression into canal into inferior half of lamina of cephalad vertebrae first with small curette burr lamina and to thin and then complete resection with Kerrison rongeurs 4 Resect ligamentum flavum dissect the ligament flavum from the medial edge of the facet use a 2-0 angled curet to release adhesions between the facet joint capsule and the ligamentum flavum resect the medial 3mm of the facet with a Kerrison punch use Kerrison to resect caudad lamina from inferior vertebra J Foraminotomy and Nerve Root Identification 1 Perform foraminotomy use a Kerrison punch and angle it out of the foramen of the traversing nerve root 2 Remove remaining ligamentum flavum with a rongeur 3 Visualize the dura once visualized take a penfield 4 and identify the lateral edge of the traversing nerve root 4 Control epidural bleeding use a combination of bipolar cautery and thrombin soaked gel foam to gain hemostasis 5 Mobilize the traversing nerve root toward the midline this visualizes the disk space place a nerve root retractor around the root and hold the nerve toward the midline use bipolar cautery to coagulate epidural vessels over the disk herniation K Microdiscectomy 1 Excise disk use a no. 15 blade to make a slit incision over the disk herniation if the herniation contains lov viscosity material then aspirate the material into the suction tip with high viscosity material use a micropituitary rongeur to remove the material make several passes until all herniated material has been removed L Address Interoperative Complications including Dural Tear Repair 1 Perform water tight closure use 4-0 nurulon to close primarily place a fat graft to reinforce the dural closure N Wound Closure 1 Irrigation, hemostasis, and drain flush out spine with saline bulb irrigation 2 Close Fascia close fascia with 1-vicryl need water tight closure and need to decrease dead space for hematoma 3 Superficial closure subcutaneous with 2-0 vicryl skin closure with buried 3-0 monocryl 4 Dressing soft incision dressings over spine
O Perioperative Inpatient Management 1 Writes appropriate admission orders IV fluids DVT prophylaxis pain control advance diet when flatus returns foley out when ambulating check appropriate labs wound care changes dressing on POD #2 identifies CSF leak 2 Appropriate medical management and medical consultation 3 Prescribe outpatient physical therapy no lifting more than ten pounds no bending no twisting perform isometric, core and hamstring flexibility exercises 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for highly complex cases (revision surgery) 2 Develop unique complex postoperative management plans when indicated