![]() The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. There was a good fill to the vertebral body edges, up towards the superior end plate, and across the midline. The balloons were then deflated and removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion.(This describes how the area is enlarged and the cement is placed in a kyphoplasty procedure.) This was done carefully and sequentially to make sure there were no cement extrusions, which, after inspection, there were none. In a similar fashion, the same thing was done on the other side. It is percutaneous using trocars.) The drill was placed into the vertebral body followed by the Kyphon bone tamp. A Kyphon trocar was passed down to the superior lateral edge of the pedicle, through the pedicle, and into the vertebral body in the usual fashion.(This describes the approach to the defect. 0.5% Marcaine with epinephrine was injected. ![]() Using biplane image intensifiers, the skin incision sites were marked. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. General anesthesia was used.) in a supine position. PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. Most of the softness was in the back part of the vertebral body. At surgery, L2 had some scalloping of the superior end plate. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. She initially had very good results, but then developed back pain once again. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.) FINDINGS PREOPERATIVELY: She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. CASE 1 PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.
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