PREOPERATIVE DIAGNOSIS: Suspicion of epidural abscess without the ability to obtain a radiologic procedure. The patient had 1-day history of urinary incontinence and 10-day history of a superficial wound infection on by mouth (p.o.) antibiotics and complained of beginning to feel lower extremity weakness and pain.
POSTOPERATIVE DIAGNOSIS: Superficial fat infection without significant infectious process below the fascia.
PROCEDURE: Exploration of wound from previous laminectomy site with irrigation and debridement, removal of scar tissue/granulation tissue, and placement of drain.
ESTIMATED BLOOD LOSS: 100 mL.
SPECIMEN: Aerobic and anaerobic cultures sent.
ANESTHESIA: General anesthesia was performed by anesthesiologist,
COUNTS: Sponge and needle counts were correct.
OPERATIVE INDICATIONS: This is a 46-year-old white male, who presented to the office with signs and symptoms of above-mentioned diagnosis. He was sent for a stat MRI, which was declined by the hospital due to a bone growth stimulator being in place. CT myelogram was not appropriate due to the fact that if an infectious process did exist traversing that and then puncturing the thecal sac could present a meningitis situation. Therefore, it was determined that surgical exploration of the wound and infection was warranted.
DESCRIPTION OF THE PROCEDURE: Once the patient was taken to the hospital, he was directly admitted and then taken to the operative suite the same night of surgery, being admitted, late in the evening and taken to surgery, in the early morning. The incision was opened after the patient had been moved from the gurney after intubation and appropriately padded and positioned. Then he was sterilely prepped and draped in the usual fashion.
After this, a sharp incision over the previously incised area was made using a #10 scalpel and carried down into the subcutaneous fat layer. Once the subcutaneous fat layer was exposed using a Weitlaner retractor, all points of bleeding were controlled with unipolar cautery, and then a Leksell rongeur was used to remove necrotic tissue and expose the area where a superficial infection could be seen. There was no frank fluid collection or pus pocket, instead just necrotic tissue. The fascia was then opened using Metzenbaum scissors for removal of sutures. The sutures were all removed using a hemostat, and then an Adson-Beckman retractor was used to spread the paraspinal muscles.
The space between the paraspinal muscles and down to the thecal sac and nerve roots where the decompression was performed did not show any signs of infectious process nor of hematoma or of large fluid collection. The wound was inspected and any additional scar tissue which had grown in the interim was removed carefully with a curved curette, pituitary forceps, and nerve hook. Once the nerve root and thecal sac were once again investigated and made sure that they had been decompressed and that there was no fluid pocket either under, superior to, or lateral to the thecal sac and nerve roots, then the wound was copiously irrigated with antibiotic solution, and then hemostasis was achieved with Surgiflo.
Once good hemostasis was achieved, then the muscular layer was closed with 0 Nurolon but not before inserting a 10-French Jackson-Pratt drain over the area of surgery above the dura and brought out through the skin after making a stab incision with a 15 blade and using a hemostat to create a tunnel. Once this was done, then the dorsolumbar fascia was completed in its closure. Then the superficial fatty layer was closed in an interrupted fashion with 0 Nurolon, and then the skin was closed using skin staples. Once the skin staples were in place, then the skin was cleaned with antibiotic solution again, and then folded 4 x 4 flaps were placed with a drain dressing placed around the drain opening. A pair of OpSite were placed over the incision and dressing.
The patient was then removed from the operative table in satisfactory condition.