It was reported that on (b)(6) 2012 the patient underwent 1) gill procedure at l5.2) laminectomy, bilateral at l4 3) foraminotomies, bilateral, at: l3-4, l 4-5 and l5-s1.4) internal stabilization from l1 through s1, bilateral, using a pedicle screw and rod system.5) posterior and lateral mass fusion from l1 through s1, bilateral, using autogenous bone plus autologous bone plus bone morphogenic protein.6) preparation of bone graft.7) intraoperative fluoroscopy.Perop notes: the greatest instability was at l5-s1 as anticipated.The spinous processes were resected from l1 through s1.This plus all additional bone removed was debrided of attached soft tissue, mixed with 90ml of cancellous bone chips hydrated in antibiotic containing saline solution, and morcellated in a bone mill for later use of graft.After this gill procedure was carried out.After foraminotomies were carried out at l3-4, l4-5, l5-s1, a bilateral laminectomy was also carried out at l4 including medial facets on each side.Following the completion of the decompressive portion of the procedure, the thecal sac and exiting roots were free of the extrinsic distortion.The remaining bone posteriorly was decorticated with a drill.The facet joint cartilage was resected with a drill and rongeurs.Holes were made through the pedicles bilaterally with a drill at l1, l2, l3, l4, l5 and s1.The holes were tapped and then variable angle head pedicle screws were placed at each site under fluoroscopic control.A single crosslink completed the construct.This provided the rigid stability across the operated levels and returned to the spine to normal alignment.The bone graft prepared, as previously described, was placed bilaterally over the decorticated bone from l1 through s1 and packed within the remaining facet joint spaces.Two large rhbmp-2/acs packages were reconstituted according to the supplier's instructions and allowed to assimilate for more than 45 mins.The rhbmp-2/acs was carefully placed over the bone graft bilaterally from l1 through s1, taking care to make sure none entered the spinal canal at any time.
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