Microdiscectomy / Laminotomy (Lumbar)
Dr. Aaron Wey
Covers CPT 63030 (laminotomy w/ decompression nerve root, 1 interspace lumbar) ± 63035 (each addl). Open or tubular.
Attire
Size 8 gloves — Biogel underneath + size 8 white gloves on top
Size XL gown ×3
Position & table
- Prone on Wilson frame on OSI Jackson table, arms in superman position on armboards. Foam eggcrate; protect knees; pillows under legs to flex hips.
- Set the spine frame on the OSI table to the lowest hole/setting at the head, and the lowest hole setting at the foot
Prep, drape & cautery
| Item — exact product | Size | Vendor | Catalog # | Open | PRN |
|---|---|---|---|---|---|
| Positioning · warming · DVT prophylaxis (non-sterile, in room) | |||||
| Sequential compression device (SCD) pump | Cardinal / Kendall | SCD 700 | 1 | ||
| SCD compression sleeves (Vasopress), size to patient | M / L | Cardinal | VP501MG / VP501LG | 1 pr | |
| Forced-air warming blanket, upper body (Bair Hugger) + unit | 3M | 52200 | 1 | ||
| Foam positioning kit / arm pads / gel rolls | Xodus | SPK10113 | 1 | ||
| Surgical skin marker (black) + field marker (purple) | Viscot | 1450XL | 1 | ||
| Foley catheter + insertion tray, 16 Fr | 16 Fr | BD | 903016A | 1 | |
| Skin prep · antisepsis | |||||
| Chlorhexidine (Hibiclens) scrub brush | 1 | ||||
| ChloraPrep applicator — 2% CHG / 70% IPA, tinted | 26 mL | BD (CareFusion) | 930815 | 2 | |
| BD Surgiphor wound irrigation — 0.5% PVP-I | 450 mL | BD | 910110 | 1 | |
| Major basin pack (RSP) | Novo Health | 124514C | 1 | ||
| Mastisol liquid adhesive vial | 0.66 mL | Ferndale | 52348 | 1 | |
| Draping | |||||
| Blue OR towels (per pack) | 17×30 in | Medical Action | 7048 | 2 | |
| Steri-Drape impervious towel drape ('1010') | 23×35 in | 3M | 1010 | 4 | |
| Medline InvisiShield towel drape ON ROLL (prep stand) | 18×12 in | Medline | DYNJSD1000RL | 1 | |
| Medline Sterile Surgical Utility Drapes with Tape, 200 EA/CS | 38×66 cm | Medline | DYNJP2405 | 4 | 2 |
| Ioban 2 antimicrobial incise drape (iodophor) | 33×35 in | 3M | 6651EZ | 1 | |
| Spine custom pack (PPMC) | Medline | DYNJ69083 | 1 | ||
| Split-sheet drape | 77×120 in | Medline | DYNJP8304 | 1 | |
| 3/4 sheet drape | Medline | DYNJP2414 | 1 | ||
| C-arm drape (PPMC Ecolab / CCH Tidi C-Armor) | 27×60 in | Ecolab / Tidi | 4951 / 5523 | 1 | |
| Skin stapler | 35 W | Covidien Appose | 8886803712 | 1 | |
| Sponges | |||||
| Raytec gauze sponge, 12-ply, X-ray detectable | 4×4 in | Cardinal Health | 6939 | 2 | |
| Laparotomy sponge (lap pad), 18×18, per pack | 18×18 in | Medline | MDS72038 | 2 | |
| Lap-tape sponge (long/thin), X-ray detectable — narrow channels / gutters | 4×18 in | Medline | MDS251504LF | 1 | 2 |
| Cottonoid patty (neuro) | 0.5×0.5 in | Integra | 801400 | 1 | |
| Sharps · needles · syringes | |||||
| Surgeon's blade #10 / #15 | #10 / #15 | Aspen | 371110 / 371115 | 1 ea | |
| Surgeon's blade #11 | #11 | Aspen | 371211 | 1 | |
| Hypodermic needle 22G / 25G | BD | 305127 | 1 | ||
| IV catheter / angiocath 18G (local / irrigation) | 18G | BD | 381454 | 1 | |
| Luer-lock syringe 20 cc | BD | 302830 | 1 ea | ||
| Spinal needle — level localization 18G | BD | 405181 | 1 | ||
| Needle counter box, magnetic | 40-ct | Medline | NC40FBR | 1 | |
| Hemostasis | |||||
| Floseal (10 cc), bone wax | ✓ | ||||
| Recothrom + Thrombin 5000 units – uses on cottonoids | ✓ | ||||
| Surgifoam soaked with 4 mg Decadron, Gelfoam size 100 | ✓ | ||||
| Surgicel PRN | ✓ | ||||
| Cautery & suction | |||||
| ESU pencil + integrated holster | Valleylab / Bovie | E2515H / ESPH | 1 | ||
| Bovie tip scratch pad | Bovie | ESSP | 1 | ||
| Bipolar forceps cord + adaptor (Storz) + pedal | Storz | — | 1 | ||
| Grounding pad / return electrode (REM) | Medtronic | 7507 | 1 | ||
| Yankauer suction tip | Sage | 006629 | 1 | ||
| Disposable plastic Frazier suction tips — 16Fr ×2, 12Fr ×2, 10Fr ×2 | 1 | ||||
| Neptune 2 Ultra suction unit + tubing + canister | Stryker | — | 1 | ||
| Closure · drains · dressing | |||||
| Fascia: #1 Vicryl (GS-21) | ✓ | ||||
| Subcut/dermis: 2-0 Vicryl | ✓ | ||||
| Skin: 3-0 clear Stratafix (or V-loc) | ✓ | ||||
| Skin glue – Dermabond | ✓ | ||||
| None typically. | ✓ | ||||
| Small Telfa+ Tegaderm (pop tart sized) x2. | ✓ | ||||
| Cautery settings: Bovie 35 / 35 cut-coag, Bipolar 35 · 1 bovie (open) + 1 additional bovie PRN (if co-surgeon) · 2 suctions off bottom of field · grounding pad on thigh. Meds (pharmacy): Local: bupivacaine/Marcaine 0.25% PF w/ epi 1:200,000; If using 0.25% bupivacaine, give same amount as patient’s kilograms in weight; If using 0.5% bupivacaine, give ½ of patient’s kilograms in weight; Add Ketorolac Tromethamine 30mg/mL (1mL); Surgeon wants an event amount of 60mL, so add 0.9% normal saline flush to make 60mL total; TXA (tranexamic acid): 30 mg/kg load + 1 mg/kg/hr infusion throughout the case; Antibiotic: 2g Ancef unless patient has an allergy; 1g Vancomycin powder, to be placed intra-wound | |||||
Magnification
Microscope — Leica preferred (Zeiss Pentero also fine). Draped microscope.
Imaging
I prefer to perform localization with 18 gauge spinal needle and intraoperative flat plate lateral lumbar spine xray (before incision, and again – reconfirmation - after tissue dissection)
Alternatively, C-arm for level localization (marker x-ray); final films PRN.
Neuromonitoring
Not routine
Sets & instruments
- Core: Spine Basic, Lumbar Spine Extras.
- Retractor: Taylor retractors
- Phantom CS most cases; ClearLine L PRN for deep/obese; McCullough retractors opened only if specifically called.
- Curettes: Chroma-Line Curettes
- Kerrisons: Black Kerrisons (1–5 mm) or Life Spine Kerrisons
- Bipolar: Silverglide bayonet.
- Osteotome/curette: Lenox-McLaren osteotome & curette set
Bony decompression tool
Stryker 4 mm diamond tip round burr #5820-012-040D, set Stryker TPS at 25,000 RPM
Misonix MIS microhook (PRN)
Power
BoneScalpel console.
Stryker Sumex Pi Drive 2+ (primary) (PRN) / Midas Rex MR8 (alternative) (PRN)
Dural tear management (have available/PRN)
Suturable DuraGen 2×2 (only uses suturable DuraGen)
6-0 dural suture such as Nuralon or Gortex suture with Castro microneedle holders
DuraSeal/Tisseel or Stryker Adherus (Green spray dural sealant)
Hemostasis
Floseal (10 cc), bone wax
Recothrom + Thrombin 5000 units – uses on cottonoids
Surgifoam soaked with 4 mg Decadron, Gelfoam size 100
Surgicel PRN
Medications
- Local: bupivacaine/Marcaine 0.25% PF w/ epi 1:200,000.
- If using 0.25% bupivacaine, give same amount as patient’s kilograms in weight.
- If using 0.5% bupivacaine, give ½ of patient’s kilograms in weight.
- Add Ketorolac Tromethamine 30mg/mL (1mL)
- Surgeon wants an event amount of 60mL, so add 0.9% normal saline flush to make 60mL total.
- TXA (tranexamic acid): 30 mg/kg load + 1 mg/kg/hr infusion throughout the case.
- Antibiotic: 2g Ancef unless patient has an allergy
- 1g Vancomycin powder, to be placed intra-wound
Drain
None typically.
Closure
Fascia: #1 Vicryl (GS-21)
Subcut/dermis: 2-0 Vicryl
Skin: 3-0 clear Stratafix (or V-loc)
Skin glue – Dermabond
Dressing
Small Telfa+ Tegaderm (pop tart sized) x2.