Suboccipital Decompression Surgery Description Sample Report
PREOPERATIVE DIAGNOSES:
1. Chiari I malformation.
2. Cervical syrinx.
POSTOPERATIVE DIAGNOSES:
1. Chiari I malformation.
2. Cervical syrinx.
PROCEDURES PERFORMED:
1. Suboccipital decompression.
2. C1 laminectomy.
3. Duraplasty.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMEN: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has a history of headaches and neck pain, particularly after strain or any type of Valsalva maneuver.
On MRI, he was found to have a Chiari I malformation with associated cervical syrinx. The patient wanted to proceed with surgery.
He understands the risk of the procedure (suboccipital decompression, C1 laminectomy, duraplasty), which mainly consists of CSF leak, hematoma, reoperation, infection, stroke, paralysis and death. The patient signed consent to proceed with surgery.
DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the prone position with his head in a Mayfield headrest. Then, midline incision was marked, and he was prepped and draped in a sterile fashion.
Incision was made with a 10-blade scalpel and Bovie coagulator and then the incision was gradually carried down from the scalp down to the midline fascia, separating the muscles.
Then, the suboccipital area was exposed along with the arch of C1 and C2. After prompt hemostasis was accomplished, the arch of C1 was completely removed posteriorly, and suboccipital craniectomy was performed with the use of the Midas Rex.
The extent of the suboccipital decompression was approximately 3 cm on each of the midline. The arch of C2 was slightly undermined and then the dura was opened in the midline, and after decompression of the cerebellar tonsils, the dura was patched with Dura-Guard, which was sutured in placed with 4-0 Nurolon.
Hemostasis was achieved. The area of the suture was reinforced with Tisseel and Duragen. Then, the incision was closed with 2-0 Vicryl, 3-0 Vicryl and 3-0 nylon for the skin.
