OPERATIVE REPORT

PATIENT NAME
Deanna Martinez

PATIENT ID
117232

DATE OF SURGERY
05/27/----

ADMITTING PHYSICIAN
Sheila Goodman, MD, Neurosurgery

SURGEON
Sheila Goodman, MD

PREOPERATIVE DIAGNOSIS
Lateral recess syndrome at L5-S1, right.

POSTOPERATIVE DIAGNOSIS
Herniated disk at L5-S1, right.

OPERATIVE PROCEDURES
1. Lumbar laminectomy.
2. Excision of disk at L5-S1 on the right.

ANESTHESIA
General endotracheal plus Marcaine with epinephrine.

SPECIMEN REMOVED
Lumbar disk tissue.

IV FLUIDS
1500 mL crystalloid.

ESTIMATED BLOOD LOSS

Minimal.

URINE OUTPUT
500 mL clear urine.

COMPLICATIONS
None.

(Continued)
OPERATIVE REPORT

Deanna Martinez
117232
05/27/----

Page 2

PROCEDURE IN DETAIL
Proper informed consent obtained, operative site initialed. With the patient
under general endotracheal anesthesia in the prone position in the Cloward
saddle, the skin of the back was prepared in the usual sterile manner and
draped with Vi-Drapes.

A midline incision centered over L5-S1 was made and carried down to the
fascia. Marcaine 0.25% with epinephrine was injected; the facia was incised
alongside the L5 spinous process and the muscle was stripped off laterally. A
portion of the lamina of L5 was removed, and the ligamentum flavum was
incised and excised. The S1 root was immediately apparent and appeared to
be contused. When the root was retracted medially, a rather tall, discrete,
cone-shaped disk herniation about 6 mm in height was seen. The posterior
longitudinal ligament was incised, and the fragment was removed.

The interspace was then entered, and disk tissue was removed using
curettes and rongeurs. The disk was fairly healthy. There was quite a bit of
disk tissue. The wound was then irrigated with Kantrex. A Gelfoam sponge
was left in place. Closure was done with 2-0 Vicryl in both the fascia and
subcutaneous tissue. Then, 4-0 undyed Vicryl was used as a subcuticular
stitch. Sterile dressing was applied.

The patient tolerated the procedure without incident and was taken to PAR in
satisfactory condition. Once she passes all criteria, she will be transferred to
SICU for 24 hours’ observation.

______________________________
Sheila Goodman, MD
Neurosurgery

SG:JO
D: 05/27/----
T: 05/28/----