3 page operation report
11/1993
Dr. John Odom, Aurora Regional Medical Center, Colorado.
Operation: Anterior Spine Fusion From T4 to L4 with disectomys and rib and vertebral body bone graft.
Diagnosis: Advanced Idiopathic Scoliosis.
Description: With the patient under general anesthesia, she was placed on her left side so that her right side was up. Dr. Enrichs entered her back by taking out the forth rib and taking out all the rib almost back to the junction of the thorax. Once this was done, he exposed the spine from T4 all the way down to L4. When I came in, the spine was exposed.
An incision was made through the disc spaces in multiple levels and then they were rouge red out. After they had been rougered out, a periosteal elevator, Cobb type, was used to clean the end plate of the bony surface of each vertebral body in such a way that not only was the disc removed but also the end plate of the vertebra above and the vertebra below. Careful attention was taken to not injure the spinal cord by entering the spinal canal. After all the thoracic discs had been taken out, which were sticking up in a convexity as we entered the would, then we entered the lower lumbar area and took it out in the concavity and finally, into again, the convexity in the lumbar spine, taking out the disc spaces all the way down to L4. Once all of the discs were out and the rib had been cut up into tiny pieces, the rib was then inserted into the disc spaces in multiple levels except at the top where it was left so that the spine could collapse down as it was distracted. Part of the vertebral body of L3 was taken out so that in that part of the body, cancellous type bone could be placed between L3 and L4. Other pieces of vertebral body were then placed between L2 and L3. The would was irrigated several times and then closed routinely by Dr. Ehrichs.
With the patient still under general anesthesia, she was turnnd over and placed on a prone frame on the table and her back was prepped and draped in a routine manner. A longitudinal incision was made down her back all the way from T2 to S1. The periosteum from T2 down through L4 was stripped and x-rays were made to be certain of the levels. We actually had only stripped L3 and we had to strip one more level to have the body stripped down to L4. A laminotomy was carried out between L3 and L4 and the pedicles were found. Temporary Steinmann pins were placed down the pedicles on each side and x-rays were used to make certain of the position in the pedicles. After using the x-ray two or three times, we were able to then take 6.5 tap and tap the pedicle itself on each side, right and left. After the pedicles had been tapped and they were not into the canal, as we could palpate them since the laminotomy had left us enough room to palpate them easily, THRS screws were placed inn their place. Hooks were then placed at T3, right and left, under the pedicle between T3 and T4 on both sides. The hooks were then removed. Facetectomies were carried out by cutting a square piece of bone on the inferior facet so that the superior facet could be seen at each level. This was carried out the way from T4 down to L3-L4. Once the facets had all been removed, a curet was used to clean off the superior facet b y curetting off all the cartilage material. This was done bilaterally.
The right illac crest was then entered through the same midline would and, after exposing the right ileum, lon g, thin cortical strips were taken followed then by long, thin cancellous strips. The would was irrigated several times and packed with Gelfoam and closed with #1 Vicryl for the facia.
He spinous processes were then split with an osteotome from T4 all the way down to L3. They were then spread again by using a bone cutter and I cut the spinous processes into smaller pieces and then they were taken off the back. Decortication was then carri4ed out, decorticating the entire spine of the posterior elements from T3 down to L3. Careful attention was made not to take off the tops of the lamina of L3 where we had the hooks placed. Otherwise, everything was decorticated down to bleeding cancellous bone, top to bottom. Laminotomies were then carried out by taking a large rougeur and cutting out the ligament of flavum between T4-T5, T5-T6, T7-T8, T8-T9, T9-T10, T10-T11, T11-T12, T12-L1, L1-L2, L2-L3 and L3-L4. Luque wired were then placed under each one of these lamia, top to bottom, and cut and bent back to the right with the wires we were not going to use. And the wires we were going to use at the beginning were opened up so a rod could be placed on the left side. A flexed THRS rod was then bent to shape to the concavity of the lordosis of the spine and the convexity of the thoracic spine. We bent an extra amount of lordosis into the patient so that we would be able to try to gain more lordosis. The rod was then placed in the top hook and snugged down with an I bolt to the hook. A rod was also placed into the I bolt at the bottom of the hook to he pedicle screw. Actually, the pedicle screw part was done before the hook at the top. The amount of lordosis was a much as possible. To help this along, we raised the lower extremities up in such a manner that the patient was placed into lordosis while she was still lying on the table. Wires were then used to twist around the rod and hold the rod down in place very snugly, top to bottom. The rod was jacked out a bit and the curve was corrected a bit. The pedicle screw was placed on the right as well as a hook on the right and then another long rod with lordosis in the lordotic part of the lumbar spine and kyphosis was bent into the spine in the part of the kytphotic part of the spine in such a way that the hooks could be tightened down to the I bolts to the rod at the top and then to the screw at the bottom. Once this was all tightened down again, the wires were tightened up this rod very snugly and twisted down. Again, we were able to jack up the part of the hook at the top and get a little bit more correction by doing this. Cross links were then added at the top and that bottom so that the two rods were rigidly held together. The wires were then twisted again very tight and twisted down toward the midline on each side with the wires pointing caudad. The would was then irrigated several times.
Prior to putting in the metal, we put in cancellous bone graft into the facet joints on each side from top to bottom. We now added more bone, top to bottom, after the metal was in place. The would was irrigated several times and closed with #1 Vicryl for the facia, 0 Vicryl for the subcutaneous tissue and 3-0 Vicryl for the skin.
A Hhemovac was added and the p0atient lost approximately 1, 500 cc of blood during the entire 9 hour procedure.
This operation was done when I was 39 years old and I think too old to have this major bone cutting surgery done. I was in the ICU for 5 days totally knocked out. When I did wake up a few times I wanted to die from the pain, I did not care. It took 5 years to even begin to feel a bit normal. It even messed up my arms and muscles in my arms and shoulders. I could never raise my arms high above my head again, ever. Dr. Odom said I was the worst one he has ever done surgery on. He also said my bones were the hardest he had ever worked on. He also said I would need to have my bottom 2 discs done in 10 to 20 years depending on if I did things right, which back then I did not even think about. So many people are scared of fusions. I think one fusion would help you to feel better and would not really hurt your lifestyle that much. The problem with them is when you are young and you get one, the other discs above and below can be affected.
