|
It was reported that on, (b)(6) 2009 the patient underwent: removal of segmental spinal instrumentation, t3-t7.Exploration of fusion.T1-t7 segmental spinal instrumentation.T3 vertebral column resection.T1-7 posterolateral fusion using local autogenous bone.Preoperative diagnosis: non-union.Scoliosis.Per-op notes: "subperiosteal dissection was performed from t1 down to the old instrumentation.It was loose.It had pulled out.It was removed.The soft tissue was stripped of the tips of the transverse process of t1 and t2, as well as removing the pseudoarthrosis.The pedicle screws were then placed.This was done in a standard fashion by first identifying the appropriate starting points, making a cortical defect in that area, placing pedicle finder down the pedicle, palpating it, tamping it, measuring it and putting in the appropriate length screw.The screw at t1 were 6.0x30, t2 6.0x30 on the left and 5.5x30 on the right.All screws had excellent purchase." on (b)(6) 2009 the patient underwent x-rays of the thoracolumbar spine.Impression: extensive thoracolumbar sacroiliac spinal fusion.On (b)(6) 2009, patient presented with complaint of recurrent incontinence and urinary tract infection.On (b)(6) 2010, patient presented with history of urge incontinence.Patient underwent renal sonogram.Impression: possible small non-obstructing right lower pole stone.On (b)(6) 2010, patient presented with history of urge incontinence.On (b)(6) 2010, patient presented with complaint of recurrent urinary tract infection and overactive bladder.On (b)(6) 2011, patient presented with complain of back infection.Patient reported that wound started draining in middle of (b)(6) with blood and pus coming out which was followed by yellow fluid coming out.On (b)(6) 2011, patient presented for follow-up on post-op wound infection.Patient reported pain in lower back area, below the wound.On (b)(6) 2011, patient presented with complaints of dysuria and urge incontinence.On (b)(6) 2010, (b)(6) 2011, (b)(6) 2012, patient presented with history of recurrent urinary tract infection.On (b)(6) 2012, patient presented for follow-up on post-op wound infection.Patient reported low back pain, below wound, occasional neck pain and upper thoracic wound opened on (b)(6) with purulent drainage and had enlarged with no surrounding erythema or induration.The left and second toe nail have orange brown discoloration underneath the nail for last two months and started from end of the nail.On (b)(6) 2012, patient underwent x-ray.Impression: contrast media was introduced into the subcutaneous tissue through a catheter with several small tributaries, however, it remained in the localized area overlying the sacroiliac joint.Under aseptic conditions the catheter was introduced in the opening in the lower cervical and upper thoracic region posteriorly.Contrast media was introduced through the catheter which remained in the subcutaneous tissue.A total of 40cc of contrast media was used.Some of the contrast media leaked out of the openings.The pedicle screws and spinal rods extending from approximately t2 through s2.On (b)(6) 2012, patient presented for follow-up on post-op wound which opened up in 2010.Patient reported small pieces of metal coming out of the wound and wound size had decreased after dressing with silvadene cream.On (b)(6) 2012, patient presented for follow-up on infection.On (b)(6) 2012, patient presented for follow-up on right total hip replacement done nine years ago.Patient underwent x-ray of right hip for follow-up on right total hip replacement.Impression: stable right total hip replacement.Patient underwent x-ray of pelvis for follow-up on right total hip replacement.Impression: stable right total hip replacement.On (b)(6) 2012 the patient underwent x-rays of the chest.Impressions: no acute disease.Also underwent x-rays of thoracolumbar spine.Impressions: bilateral harrington rods extending from l1 to s2.A mild thoracic ureter convexed was left is present.No hardware failure is present.Multiple mild chronic compression fractures of several mid to lower thoracic vertebral bodies.On (b)(6) 2012, patient underwent following procedure: removal of t1 to s1 and pelvis instrumentation (stainless steel), exploration of fusion, re-instrumentation t1 to t12 with titanium, t1 to t7 posterolateral fusion using autogenous bone, 1 large kit bmp, 10ml of bone graft; for pre-op diagnosis of: drainage from spine secondary to possible infection, non-union, scoliosis, stenosis.Per-op notes: "the screws were all removed in lumbar spine as well as the pelvis.Again, there was little pockets of pus associated with the pelvic wing screws.The fusion appeared solid.We replaced thoracic screws with 70 x 40 at t10, t11, t12 on the right and t11 and t12 on the left.The t9 screw did not appeared to be good so it was left out.The bone graft was performed after decortication.Patient was taken to recovery room in stable condition." on (b)(6) 2012 the patient underwent x-rays of the thoracolumbar spine.Impressions: post revision of spinal fusion.Minimal midthoracic scoliosis convex to the left.On (b)(6) 2012, patient presented for follow-up after removal of stainless steel rods and placement of titanium rods.On (b)(6) 2012, patient presented for follow-up two weeks post-op removal of instrumentation from t1 to pelvis and re-instrumentation t1-t12.Scoliosis x-rays showed remaining thoracic instrumentation in good position from t1 to t12.On (b)(6) 2012, patient presented for post-op follow-up.On (b)(6) 2012, patient presented with complaints of dysuria and urge incontinence.Patient reported incontinence and severe pain.On (b)(6) 2012 the patient underwent x-rays of the lumbosacral spine and thoracic spine.Impression: no fracture-dislocation lumbosacral spine.No change in alignment of lumbar sacral spine.Posterior bony fusion and resection of posterior spinous processes unchanged from (b)(6) 2012 scoliosis films.Status post posterior surgical fusion od thoracic spine with alignment unchanged.Metallic cylinder in place and upper thoracic spine unchanged.The patient also underwent mri of the thoracic spine.Impressions: multi level post-operative change again noted with extensive artifact significantly limits evaluation of the thoracic spine.Scattered degenerative change.No definite spinal cord deformity.Follow up ct myelogram could be performed for further evaluation if needed.The patient also underwent x-rays of the lumbar spine.Impression: extensive post operative change status post anterior lumbar discectomy bony fusion extending l2-3 through l5-s1.Prior hardware removal partial posterior decompressions posterior lateral bony fusions.Persistent hardware fusion again noted lower thoracic spine.A large septated fluid collection in posterior para spinous soft tissue as above possible minor foci of air.Although this may be secondary to post operative change hematoma, seroma infection abscess is not excluded.Multilevel spinal stenosis most marked with moderate spinal stenosis l5-s1.Multilevel foraminal narrowing most marked right l4-5 bilaterally l5-s1 greater right.Scattered degenerative change elsewhere are lower thoracic lumbar spine.Slight loss of lordosis minor multilevel anterior retrolisthesis scoliosis.On (b)(6) 2012 the patient underwent ct scan of the lumbar and thoracic spine.Impression: ct guided aspiration of lumbar paraspinal fluid.Deep midline posterior fluid collection extending along the lumbar spine.Fluid was aspirated for cultures.No complications were noted.The patient underwent mri of the lower back.Impressions: once again, exam significantly limited secondary to extensive post operative fusion changes through out the thoracic spine resulting susceptibility artifact.Allowing for these limitations, there is no obvious new compression fracture or spondylolisthesis.No obvious new vertebral body or disc space edema evident that would clearly indicate osteomyelitis.No definite new large disc extrusion or spinal stenosis although evaluation must be considered limited for these purposes.No obvious new paraspinal soft tissue inflammatory collection or fluid collection identified, although once again, evaluation limited.Somewhat smaller but still extensive rim-enhancing deep midline posterior fluid collection, consistent with hematoma, seroma, or csf pseudocyst, potentially infected.This is certainly amenable to percutaneous aspiration.No findings indicative of osteomyelitis.Post operative changes from spinal fusion.Pre-existing fusion rods on the lower thoracic and upper lumbar levels.These extend to l1 inferiorly.On (b)(6) 2012, patient presented for follow-up.Patient reported pain.Mri of thoracic and lumbar spine showed a lot of fluid collection.On (b)(6) 2012, patient presented for follow-up and reported back pain, located over lower back and hip area.Patient reported that three weeks after surgery she developed urinary incontinence.On (b)(6) 2012, patient presented for follow-up on seroma on lower back.Patient reported moderate pain in left hip region which radiates down the leg.On (b)(6) 2012, patient presented for follow-up.Patient reported low back pain.Scoliosis x-ray showed instrumentation from t1 to t12.She had good balance and correction of deformity was maintained.On (b)(6) 2012, patient presented for follow-up.Urine culture was tested positive two weeks ago.On (b)(6) 2012, patient presented with complaints of dysuria and urge incontinence.Patient also reported nocturia.On (b)(6) 2012, (b)(6) 2013, patient presented for follow-up and evaluation on post-op back infection.On (b)(6) 2012, patient presented for six month follow-up for fusion and removal of instrumentation.Patient reported occasional back pain.Scoliosis x-ray showed instrumentation from t1 to t12.On (b)(6) 2013, patient presented for office visit with chief complaint of history of urinary tract infection.On (b)(6) 2013, (b)(6) 2014, (b)(6) 2015, patient presented for follow-up on treatment and evaluation of prosthetic spinal hardware infection.Patient reported mild pain.On (b)(6) 2013, patient presented for follow-up on recurrent urinary tract infection and history of overactive bladder.On (b)(6) 2013, patient presented for follow-up on treatment and evaluation of prosthetic spinal hardware infection.Patient reported a click in hip.X-ray was done which showed no abnormalities.On (b)(6) 2014, patient presented with recurrent urinary tract infection, urgency/frequency.On (b)(6) 2014, patient presented with complaints of overactive bladder.On (b)(6) 2014, patient presented for follow-up on right total hip replacement 11 years post-op.Patient underwent x-ray of right hip for follow-up on right total hip replacement.Impression: stable right total hip replacement.Patient underwent x-ray of pelvis for follow-up on right total hip replacement.Impression: stable right total hip replacement, mild to moderate osteoarthritis left hip.On (b)(6) 2015, patient presented for office visit with complaints of overactive bladder.
|
