AI Scribe for Neurosurgeons

OPERATIVE REPORT
Date of Surgery: 2026-04-22
Surgeon: A. Reyes, MD
Assistant: T. Nguyen, MD (PGY-6, Neurosurgery)
Anesthesia: General endotracheal with TIVA (propofol/remifentanil) for SSEP/MEP fidelity (Dr. Halloran)

PRE-OPERATIVE DIAGNOSIS:
L4-L5 grade I degenerative spondylolisthesis with bilateral lateral recess stenosis and L5 radiculopathy refractory to 9 months of conservative care (M48.062, M51.16)

POST-OPERATIVE DIAGNOSIS:
Same

PROCEDURE PERFORMED:
1. L4-L5 posterior lumbar interbody fusion (PLIF) (CPT 22630)
2. L4-L5 segmental posterior instrumentation, two segments (CPT 22842)
3. L4-L5 anterior interbody PEEK cage (CPT 22853)
4. L4-L5 bilateral facetectomy and laminectomy with central and lateral recess decompression (CPT 63047)
5. Local autograft and allograft (CPT 20930/20936)
6. Intra-operative neuromonitoring with SSEP and MEP, interpreted in real time (CPT 95941, by neuromonitoring service)

ASA CLASS: III (DM2 A1c 7.4, BMI 31, controlled HTN)
HOLD STATUS: Aspirin held 7 days, NPO since midnight, prophylactic enoxaparin held morning of surgery
ANTIBIOTICS: Cefazolin 2 g IV at 07:38, 22 minutes before incision; redosed at 4 hours
TXA: 1 g IV at induction, 1 g during closure
NEUROMONITORING: SSEP and MEP baselines stable bilaterally; no alerts during the case

INDICATION:
58-year-old male with 9 months of progressive bilateral leg pain, neurogenic claudication at 1 block, and L5-distribution paresthesias. Exam shows 4/5 EHL bilaterally and L5 dermatomal sensory loss. MRI lumbar spine 2026-03-10 (radiology read by Dr. Patel): grade I L4-on-L5 spondylolisthesis with severe bilateral lateral recess stenosis, broad-based disc protrusion, and ligamentum flavum hypertrophy. Failed 9 months of PT, two epidurals, and an oral steroid course. Risks of bleeding, infection (1–2%), CSF leak (2–4% in instrumented cases), nerve root injury, hardware failure, adjacent-segment disease, and DVT/PE were discussed in detail with the patient and his wife in clinic on 2026-03-28 and again in pre-op holding. Patient consented.

POSITION: Prone on Jackson table over Wilson frame; pressure points padded; arms tucked.

FINDINGS:
- Grade I L4-on-L5 spondylolisthesis confirmed on intra-op fluoroscopy
- Severe bilateral lateral recess stenosis from facet hypertrophy and ligamentum flavum buckling
- Annular disruption at L4-L5 with extruded disc material at the right L5 axilla
- Bilateral L5 traversing nerve roots tethered and compressed; freely mobile after decompression
- No dural tear; pulsatile dura and nerve roots after final decompression
- No CSF leak

PROCEDURE NARRATIVE:
After confirmation of consent and side, the patient was brought to the OR and induced. SSEP and MEP electrodes placed and baselines recorded. Patient positioned prone on a Jackson table with a Wilson frame; pressure points and eyes confirmed clear. Lumbar spine prepped with chlorhexidine and draped. Time-out performed.

A 5 cm midline incision was made over L4-L5 confirmed by fluoroscopy. Subperiosteal dissection of paraspinal muscles bilaterally exposed L4 and L5 lamina, facets, and transverse processes. AP and lateral fluoroscopy confirmed levels.

Pedicle screws placed under fluoroscopic guidance: L4 6.5 × 45 mm bilaterally; L5 7.0 × 45 mm bilaterally. All four screws probed with a ball-tipped feeler — medial and inferior walls intact. Triggered EMG > 12 mA at all four screws (no breach signal). SSEP and MEP unchanged.

Bilateral L4-L5 facetectomy and central laminectomy performed with high-speed drill and Kerrison rongeurs. Ligamentum flavum resected. Bilateral L5 nerve roots fully decompressed in the lateral recess and foramen. Roots gently retracted; annular fibers incised; disc material removed with pituitary rongeurs. Disc space prepared with shavers, curettes, and rasps to bleeding endplates.

A 10 mm × 28 mm PEEK interbody cage filled with morselized local autograft and allograft was packed and inserted from the right side. Lateral fluoroscopy confirmed mid-vertebral position. Posterolateral gutters decorticated; remaining graft placed bilaterally.

5.5 mm titanium rods contoured to lumbar lordosis, seated, set screws torqued to specification. Final fluoroscopy: anatomic alignment, hardware in expected position. Hemostasis achieved with bipolar and Floseal. Vancomycin powder 1 g sprinkled in the wound.

Wound irrigated with 2 L warm saline + bacitracin. Fascia closed with #1 Vicryl, subcutaneous with 2-0 Vicryl, skin with 3-0 Monocryl subcuticular and Dermabond. Sterile dressing applied.

ESTIMATED BLOOD LOSS: 350 mL
URINE OUTPUT: 400 mL
IV FLUIDS: 2.0 L lactated Ringer's
TRANSFUSIONS: None
SPECIMENS: Disc material to pathology; Bone fragments retained for graft.
COMPLICATIONS: None. Neuromonitoring stable throughout.

DISPOSITION:
Patient extubated in the OR, neurologically intact, transferred to PACU then to the neurosurgical floor. Plan: log-roll precautions × 24 h, lumbosacral orthosis when out of bed, PT at POD 1 with weight-bearing as tolerated, dexamethasone 4 mg IV q6h × 24 h then off, gabapentin 300 mg TID for neuropathic component, oxycodone 5 mg q4h PRN with bowel regimen, enoxaparin 40 mg daily restarting POD 1, AP/lateral lumbar films at 6 weeks. Target discharge POD 2 if pain controlled and ambulating with PT.