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Page 1: Proofreading & Editing Exercise Report #5downloads.lww.com/wolterskluwer_vitalstream_com/sample-content...Proofreading & Editing Exercise Report #5 LAMINOTOMY, DISCECTOMY, ... PREOPERATIVE

PROOFREADING AND EDIT ING EXERCISES 127

Proofreading & Editing Exercise Report #5

L A M I N O T O M Y , D I S C E C T O M Y , A N D F O R A M I N O T O M YO F L 5 - S 1 , W I T H E P I D U R A L S T E R O I D I N J E C T I O N

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1, left, with foraminalstenosis.

POSTOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1, left, with foraminalstenosis.

OPERATION:1. Laminotomy, discectomy, L5-S1, with foraminotomy, left.2. Injection of epidural steroid under direct visualization.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

FINDINGS: Significant stenosis around the exiting nerve root at L5-S1 with mildcompression upon the L5 nerve root superiorly.

HISTORY: This is a 38-year-old male known to me for some time. He has pain in hisback and left leg about which we have had multiple discussions in the office. Heunderstands that fusion would probably be the optimal procedure for him, althoughhe did not want this as it may limit his job abilities. He understands that we areaiming to improve the leg pain; he most probably will still have significant back pain.His leg paresthesias are so severe they are limiting his ability to work. He now wishesto forego any further conservative treatment and to undergo surgical decompression.He is well aware of the risks, benefits, and potential outcomes of operative andnonoperative treatments. Specifically, the risks of surgery include, but are not limitedto, the risk of infection and delayed wound heading, which is increased given hissmoking. (He was instructed to cease this prior to and after the surgery.) Heunderstands the risk of recurrent herniation, failure to relieve his symptoms, spinalfluid leak, injury to nerves or blood vessels, excessive bleeding, and the need forfurther operations. He has voiced understanding and agrees to go forth with surgery.

PROCEDURE: The patient was taken back to the operating theater, given a generalanesthetic, and placed in a prone position on the Wilson frame on a Jackson table.Prep and drape was done in the usual sterile fashion. C-arm image intensificationwas utilized to identify the L5-S1 interspace.

Dissection was done at L5 and S1 with a knife, with subperiosteal dissection achievedwith Bovie electrocautery. The L5-S1 interspace was identified and reconfirmed withC-arm image intensification. A Taylor retractor was placed, and attention was turnedto laminotomy with discectomy. An angled curette was utilized to remove theligamentum flavum off S1 and L5. This was freed with an elevator. A cotton pledgetwas placed underneath the ligamentum. An Anspach drill was utilized to thin the

(continued)

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Page 2: Proofreading & Editing Exercise Report #5downloads.lww.com/wolterskluwer_vitalstream_com/sample-content...Proofreading & Editing Exercise Report #5 LAMINOTOMY, DISCECTOMY, ... PREOPERATIVE

128 CREATING ORTHOPAEDIC REPORTS

lamina at L5. Laminotomy then ensued with Kerrison rongeur at L5 as well as S1.The nerve root was identified and retracted for safety. Hemostasis at this level wasachieved with bipolar electrocautery as well as thrombin-soaked Gelfoam and acotton pledget. The disc was identified, incised, and removed with pituitary rongeurs.Foraminotomy then ensued, and in fact there was significant stenosis at the level ofthe foramen. The nerve root was found to be free and clear after the foraminotomy.This area was packed with thrombin-soaked Gelfilm and cotton pledgets.

Copious irrigation ensued, and final hemostasis was assured. Under directvisualization, 80 mL of Depo-Medrol was injected into the epidural space.

Attention was turned to closure. The wound was closed with �1 Vicryl, followed by2-0 Vicryl, followed by 3-0 running subcuticular Vicryl. Sterile dressings were placed.The patient was awakened and taken to PACU in stable condition.

95269_P3 7/9/07 12:29 PM Page 128

Page 3: Proofreading & Editing Exercise Report #5downloads.lww.com/wolterskluwer_vitalstream_com/sample-content...Proofreading & Editing Exercise Report #5 LAMINOTOMY, DISCECTOMY, ... PREOPERATIVE

216 CREATING ORTHOPAEDIC REPORTS216 CREATING ORTHOPAEDIC REPORTS

(continued)

s/b healing,typographicerror

Answer Key Report #5

L A M I N O T O M Y , D I S C E C T O M Y , A N D F O R A M I N O T O M YO F L 5 - S 1 , W I T H E P I D U R A L S T E R O I D I N J E C T I O N

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1,left, with foraminal stenosis.

POSTOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1,left, with foraminal stenosis.

OPERATION:1. Laminotomy, discectomy, L5-S1, with foraminotomy, left.2. Injection of epidural steroid under direct visualization.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

FINDINGS: Significant stenosis around the exiting nerve root at L5-S1 with mild compression upon the L5 nerve root superiorly.

HISTORY: This is a 38-year-old male known to me for some time.He has pain in his back and left leg about which we have hadmultiple discussions in the office. He understands that fusionwould probably be the optimal procedure for him, although hedid not want this as it may limit his job abilities. He understandsthat we are aiming to improve the leg pain; he most probably willstill have significant back pain. His leg paresthesias are so severethey are limiting his ability to work. He now wishes to forego anyfurther conservative treatment and to undergo surgicaldecompression. He is well aware of the risks, benefits, andpotential outcomes of operative and nonoperative treatments.Specifically, the risks of surgery include, but are not limited to, therisk of infection and delayed wound heading, which is increasedgiven his smoking. (He was instructed to cease this prior to andafter the surgery.) He understands the risk of recurrent herniation,failure to relieve his symptoms, spinal fluid leak, injury to nervesor blood vessels, excessive bleeding, and the need for furtheroperations. He has voiced understanding and agrees to go forthwith surgery.

PROCEDURE: The patient was taken back to the operating theater,given a general anesthetic, and placed in a prone position on theWilson frame on a Jackson table. Prep and drape was done in theusual sterile fashion. C-arm image intensification was utilized toidentify the L5-S1 interspace.

s/b werebecause thesubject “prepand drape” isplural

95269_P3 7/9/07 12:29 PM Page 216

Page 4: Proofreading & Editing Exercise Report #5downloads.lww.com/wolterskluwer_vitalstream_com/sample-content...Proofreading & Editing Exercise Report #5 LAMINOTOMY, DISCECTOMY, ... PREOPERATIVE

ANSWER KEYS AND FOR S IGNATURE REPORTS 217ANSWER KEYS AND FOR S IGNATURE REPORTS 217

Dissection was done at L5 and S1 with a knife, with subperiostealdissection achieved with Bovie electrocautery. The L5-S1interspace was identified and reconfirmed with C-arm imageintensification. A Taylor retractor was placed, and attention wasturned to laminotomy with discectomy. An angled curette wasutilized to remove the ligamentum flavum off S1 and L5. This wasfreed with an elevator. A cotton pledget was placed underneaththe ligamentum. An Anspach drill was utilized to thin the laminaat L5. Laminotomy then ensued with Kerrison rongeur at L5 aswell as S1. The nerve root was identified and retracted for safety.Hemostasis at this level was achieved with bipolar electrocauteryas well as thrombin-soaked Gelfoam and a cotton pledget. Thedisc was identified, incised, and removed with pituitary rongeurs.Foraminotomy then ensued, and in fact there was significantstenosis at the level of the foramen. The nerve root was found tobe free and clear after the foraminotomy. This area was packedwith thrombin-soaked Gelfilm and cotton pledgets.

Copious irrigation ensued, and final hemostasis was assured.Under direct visualization, 80 mL of Depo-Medrol was injectedinto the epidural space.

Attention was turned to closure. The wound was closed with �1Vicryl, followed by 2-0 Vicryl, followed by 3-0 running subcuticularVicryl. Sterile dressings were placed. The patient was awakenedand taken to PACU in stable condition.

s/b Gelfoam,typographicerror,Stedman’sMedical &SurgicalEquipmentWords, 5E

95269_P3 7/9/07 12:29 PM Page 217

Page 5: Proofreading & Editing Exercise Report #5downloads.lww.com/wolterskluwer_vitalstream_com/sample-content...Proofreading & Editing Exercise Report #5 LAMINOTOMY, DISCECTOMY, ... PREOPERATIVE

218 CREATING ORTHOPAEDIC REPORTS

For Signature Report #5

L A M I N O T O M Y , D I S C E C T O M Y , A N D F O R A M I N O T O M YO F L 5 - S 1 , W I T H E P I D U R A L S T E R O I D I N J E C T I O N

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1, left, with foraminal stenosis.

POSTOPERATIVE DIAGNOSIS: Herniated nucleus pulposus, L5-S1, left, with foraminal stenosis.

OPERATION:1. Laminotomy, discectomy, L5-S1, with foraminotomy, left.2. Injection of epidural steroid under direct visualization.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

FINDINGS: Significant stenosis around the exiting nerve root at L5-S1 with mild compression uponthe L5 nerve root superiorly.

HISTORY: This is a 38-year-old male known to me for some time. He has pain in his back and leftleg about which we have had multiple discussions in the office. He understands that fusion wouldprobably be the optimal procedure for him, although he did not want this as it may limit his jobabilities. He understands that we are aiming to improve the leg pain; he most probably will stillhave significant back pain. His leg paresthesias are so severe they are limiting his ability to work.He now wishes to forego any further conservative treatment and to undergo surgicaldecompression. He is well aware of the risks, benefits, and potential outcomes of operative andnonoperative treatments. Specifically, the risks of surgery include, but are not limited to, the risk ofinfection and delayed wound healing, which is increased given his smoking. (He was instructed tocease this prior to and after the surgery.) He understands the risk of recurrent herniation, failure torelieve his symptoms, spinal fluid leak, injury to nerves or blood vessels, excessive bleeding, andthe need for further operations. He has voiced understanding and agrees to go forth with surgery.

PROCEDURE: The patient was taken back to the operating theater, given a general anesthetic, andplaced in a prone position on the Wilson frame on a Jackson table. Prep and drape were done inthe usual sterile fashion. C-arm image intensification was utilized to identify the L5-S1 interspace.

Dissection was done at L5 and S1 with a knife, with subperiosteal dissection achieved with Bovieelectrocautery. The L5-S1 interspace was identified and reconfirmed with C-arm imageintensification. A Taylor retractor was placed, and attention was turned to laminotomy withdiscectomy. An angled curette was utilized to remove the ligamentum flavum off S1 and L5. Thiswas freed with an elevator. A cotton pledget was placed underneath the ligamentum. An Anspachdrill was utilized to thin the lamina at L5. Laminotomy then ensued with Kerrison rongeur at L5 aswell as S1. The nerve root was identified and retracted for safety. Hemostasis at this level wasachieved with bipolar electrocautery as well as thrombin-soaked Gelfoam and a cotton pledget.The disc was identified, incised, and removed with pituitary rongeurs. Foraminotomy then ensued,and in fact there was significant stenosis at the level of the foramen. The nerve root was found to

(continued)

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ANSWER KEYS AND FOR S IGNATURE REPORTS 219

be free and clear after the foraminotomy. This area was packed with thrombin-soaked Gelfoamand cotton pledgets.

Copious irrigation ensued, and final hemostasis was assured. Under direct visualization, 80 mL ofDepo-Medrol was injected into the epidural space.

Attention was turned to closure. The wound was closed with �1 Vicryl, followed by 2-0 Vicryl,followed by 3-0 running subcuticular Vicryl. Sterile dressings were placed. The patient wasawakened and taken to PACU in stable condition.

95269_P3 7/9/07 12:29 PM Page 219