HTML Preview Patient Operative Report page number 1.
OPERATIVE REPORT
PATIENT NAME: ___[NAME]
MR#: ___[MR#]
ADMIT DATE: ___[DATE]
PROCEDURE DATE: ___[DATE]
PREOPERATIVE DIAGNOSES:
1. Cervical spondylosis C5-6 and C6-7 level without myelopathy.
2. Cervical radiculitis bilateral upper extremities.
POSTOPERATIVE DIAGNOSES:
1. Cervical spondylosis C5-6 and C6-7 level without myelopathy.
2. Cervical radiculitis bilateral upper extremities.
PROCEDURE:
1. Anterior discectomy, with spinal cord decompression C5-6 level – 63075.
2. Anterior discectomy, with spinal cord decompression C6-7 level – 63076.
3. Arthrodesis interbody technique C5-6 level – 22554.
4. Arthrodesis interbody technique C7 level – 22585.
5. Anterior instrumentation three vertebral segments – 28845.
? 40 mm long Venture plate from Medtronic
6. Allograft: Structural C5-6 level – 20930.
? 5 mm high x 11 mm deep x 14 mm wide cortical cancellous allogenous bone graft.
7. Allograft: Structural C6-7 level – 20930.
? 5 mm high x 11 mm deep x 14 mm wide cortical cancellous allogenous bone graft.
8. EMG motor evoked potential testing bilateral upper extremities. Room entry time 10:37. Room exit time
12:20.
SURGEON: ___[NAME]
ASSISTANT: ___[NAME]
ANESTHESIOLOGIST: ___[NAME]
ANESTHESIA: General oral endotracheal.
DRAINS: One 0.25 inch Penrose.
ESTIMATED BLOOD LOSS: None.
COMPLICATIONS: None.
NARRATIVE: The patient is a 59-year-old white female seen in my office regarding severe posterior
cervical pain and bilateral upper extremity radicular pain and numbness. The plain films, flexion extension films,
and MRI scans have identified loss of disc space height, irregularity of the end plates, chronic disc protrusions
of C5-6 and C6-7. There is contact on the ventral cord, persistent neuroforaminal narrowing. The treatment
options were discussed and reviewed with the patient as she has failed to make progress with conservative