Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and performs focused neurological exam describe key physical exam maneuvers (lumbar nerve root function) concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests extends examination to nonspinal differential diagnostic possibilities vascular claudication hip arthritis 2 Interpret basic imaging studies interpret radiographs of the L-spine 3 Order and interpret advanced imaging studies CT scan myelogram MRI findings central stenosis foraminal stenosis identifies nerve root anatomy correlates 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 make referrals to other professionals 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 postop: ~ 3 month postoperative visit repeat xrays of lumbar spine advance spine restrictions and activity levels diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Provides complex non-operative treatment individualized care, shared decision making, comprehensive informed consent 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 Obtains history and performs basic neurologic Exam need to carefully document neurological status of bilateral lower extremities strength, sensation, reflexes, and primary symptoms 2 Order basic imaging studies order biplanar 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 3 Recognizes indications for and initiates immediate additional work-up ("Red Flags") or urgent surgical care cauda equina syndrome progressive deficit 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 persistent radiculopathy due to inadequate decompression dural tear iatragenic nerve root injury segmental instability due to aggressive facet capsule and joint excision superficial, deep wound infection meralgia parasthetica due to compression of LFCN Operative Techniques 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 laminectomy 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 Superficial Dissection to Expose Spinous Process 1 Localize level of incision with anatomic or radiographic landmarks 2 Make midline incision. midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae) ~3-4cm in length for single level 3 Dissect subcutaneous tissue down to fascia insert cerebellar retractors x2 for fascial exposure 4 Cauterize lumbodorsal fascia over spinous processes to just lateral of midline H Deep Dissection down to Lamina 1 Subperiosteal dissection with Cobb along spinous processes 2 Subperiosteal dissection of lamina cranial to caudal down to lamina 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 Laminectomy and Central Decompression 1 Remove spinous processes of operative levels with rongeur save as bone graft for fusion 2 Remove lamina and identify origin of ligamentum flavum 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 3 Resect ligamentum flavum gently retract ligamentum flavum with woodsen elevator resect remaining lamina and ligamentum with Kerrison rongeur of cephalad vertebrae resect ligamentum from superior lamina of inferior lamina use Kerrison to resect caudad lamina from inferior vertebra J Lateral Recess and Foraminal Decompression 1 Perform Medial facetectomy decompress medial aspect of facet on each side (2-3 mm of medial facet) 2 Decompress lateral recess locating pedicle key to safe decompression kerrison to undercut medial edge of superior facet of caudad vertebra until medial edge of pedicle visualized identify osteophytes that could impinge exiting nerve root around pedicle undercut remaining superior facet using kerrison rongeur no more than 50% superior facet should be resected 3 Confirm exiting and descending nerve roots are well decompressed descending nerve root should be visualized 4 Check to make sure no disc herniation. Dural sac/nerve root may be retracted to see if there is bulging disc is present K Wound Closure 1 Irrigation, hemostasis, and drain flush out spine with saline bulb irrigation 2 Deep closure close fascia with 0-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 Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs appropriate wound care changes dressing on POD #2 identifies CSF leak foley catheter out when ambulating 2 Appropriate medical management and medical consultation 3 Orders appropriate inpatient occupational and physical therapy weight-bearing as tolerated, physical and occupational therapy no heavy lifting and limited flexion/extension 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks wound care 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 Develops unique complex postoperative management plans when indicated
A Outpatient Evaluation and Management 1 Obtain focused history and performs focused neurological exam describe key physical exam maneuvers (lumbar nerve root function) concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests extends examination to nonspinal differential diagnostic possibilities vascular claudication hip arthritis 2 Interpret basic imaging studies interpret radiographs of the L-spine 3 Order and interpret advanced imaging studies CT scan myelogram MRI findings central stenosis foraminal stenosis identifies nerve root anatomy correlates 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 make referrals to other professionals 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 postop: ~ 3 month postoperative visit repeat xrays of lumbar spine advance spine restrictions and activity levels diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Provides complex non-operative treatment individualized care, shared decision making, comprehensive informed consent 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 Obtains history and performs basic neurologic Exam need to carefully document neurological status of bilateral lower extremities strength, sensation, reflexes, and primary symptoms 2 Order basic imaging studies order biplanar 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 3 Recognizes indications for and initiates immediate additional work-up ("Red Flags") or urgent surgical care cauda equina syndrome progressive deficit 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 persistent radiculopathy due to inadequate decompression dural tear iatragenic nerve root injury segmental instability due to aggressive facet capsule and joint excision superficial, deep wound infection meralgia parasthetica due to compression of LFCN
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 laminectomy 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 Superficial Dissection to Expose Spinous Process 1 Localize level of incision with anatomic or radiographic landmarks 2 Make midline incision. midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae) ~3-4cm in length for single level 3 Dissect subcutaneous tissue down to fascia insert cerebellar retractors x2 for fascial exposure 4 Cauterize lumbodorsal fascia over spinous processes to just lateral of midline H Deep Dissection down to Lamina 1 Subperiosteal dissection with Cobb along spinous processes 2 Subperiosteal dissection of lamina cranial to caudal down to lamina 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 Laminectomy and Central Decompression 1 Remove spinous processes of operative levels with rongeur save as bone graft for fusion 2 Remove lamina and identify origin of ligamentum flavum 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 3 Resect ligamentum flavum gently retract ligamentum flavum with woodsen elevator resect remaining lamina and ligamentum with Kerrison rongeur of cephalad vertebrae resect ligamentum from superior lamina of inferior lamina use Kerrison to resect caudad lamina from inferior vertebra J Lateral Recess and Foraminal Decompression 1 Perform Medial facetectomy decompress medial aspect of facet on each side (2-3 mm of medial facet) 2 Decompress lateral recess locating pedicle key to safe decompression kerrison to undercut medial edge of superior facet of caudad vertebra until medial edge of pedicle visualized identify osteophytes that could impinge exiting nerve root around pedicle undercut remaining superior facet using kerrison rongeur no more than 50% superior facet should be resected 3 Confirm exiting and descending nerve roots are well decompressed descending nerve root should be visualized 4 Check to make sure no disc herniation. Dural sac/nerve root may be retracted to see if there is bulging disc is present K Wound Closure 1 Irrigation, hemostasis, and drain flush out spine with saline bulb irrigation 2 Deep closure close fascia with 0-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 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs appropriate wound care changes dressing on POD #2 identifies CSF leak foley catheter out when ambulating 2 Appropriate medical management and medical consultation 3 Orders appropriate inpatient occupational and physical therapy weight-bearing as tolerated, physical and occupational therapy no heavy lifting and limited flexion/extension 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks wound care 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 Develops unique complex postoperative management plans when indicated