4th July, 2023
O.A /34YEAR/ MALE
DIAGNOSIS: Degenerative disease of cervical spine
BACKGROUND HISTORY AND PRESENTATION:
The above named patient is 34yr old man who presented weakness in his upper and lower limbs 4yrs ago, more severe on the left side. There is also associated tremors, numbness and parathesis, which is worse on the left side of the body. He has difficulty in writing or buttoning of shirt. No radicular pains. No associated history of urinary and fecal incontinence. He is not a known hypertensive/ diabetic.
Normal tone, power in all limbs, hyperreflexia noted on all limbs globally
MRI Cervical spine below C4/5 degenerative spine disease.
1. Admit patient and work up for C4/5 ACDF
2. GXM 2 units of blood.
Pre- Operative evaluation (05/07/2023)
FBC: WBC- 3.93, HCT- 39.34, PLT- 172
EUCr: Na- 142.9, K- 3.44, Ur- 44.10, Cr- 1.28
Clotting profile: PT- 12.5secs, INR- 0.9, APTT- 32.2secs
Serology: Non- reactive
Informed Consent Obtained.
OPERATION NOTE 12/07/2023
1. C4/5 herniated disc
2. Hypertrophied PLL
3. Saucerization of the cord of the C4/5 level
DETAILS OF SURGICAL PROCEDURE:
· Patient supine; GA + ETT
· Incision site identified, shaved and infiltrated with lidocaine adrenaline
· Siting was applied via a garderner’s well traction and counter traction applied via the upper limb bilaterally.
· Routine sterile cleaning and draping applied
· Incision made through the skin crease and with electrocutery device, hemostasis secured and blunt dissection done.
· Trachea and oesophagus retracted to the right, the sternocleidomastoid muscle and carotid sheath retracted to the left.
· Longus colli muscles identified and stripped off
· Intra-op identification done
· Tram-hive retractors applied and disectony done with corresponding implant (size 8) inserted.
· Drain applied and closure in layers, with a subcurticular skin closure with vicryl 3/0.
1. IVF N/S 1L 8hrly
2. IVF GKI
3. IV rocephin 1g 12hrly
4. IV tramadol 50mg 12hrly
5. IV Omeprazole 20mg daily
6. IV Dexamethasone 4mg 8hrly x 24hrs
7. Fluid input/output chart.
8. RBS check
9. Keep rigid collar in-situ for 2 weeks.
A 34years old male, who had a C4/5 ACDF done 24 hours ago on account of C4/5 disc herniation and cord compression. Patient had severe hypoglycemia yesterday, post surgery was adequately controlled. However, still having rebound hypoglycemia.
Drain had a minimal discharge and has been removed.
FBS: 1.8mmol.currently, still on 5% dextrose saline correction.
1. Inform anesthetist about development
2. Continue management.
A 34years old male, who had a C4/5 ACDF done 4 days ago on account of C4/5 disc herniation and cord compression.
No longer having pains on the limbs, moving all limbs. Blood pressure has been elevated despite being on tab amlodipine 10mg, tabs telmisartan 80mg. white blood cells elevated, PCV 30%. However, there is no fever.
O/E: conscious, mildly pale, anicteric, acyanosed.
Vital signs: BP 190/90mmHg (before antihypertensive) 160/120mmHg (after tabs amlodipine)
Wound: clean and dry
1. Change to tabs nifedipine 30mg dly
2. Tabs Zinnat 500mg 12hrly x 1/52
3. Tabs metronidazole 400mg 8hrly x 1/52
4. Tabs tramadol 50mg 12hrly x 1/52.
A 34years old male, who had a C4/5 ACDF done 5 days ago on account of C4/5 disc herniation and cord compression.
Patient is currently doing well, blood pressure fairly controlled today (140/80mmHg).
Ambulating efficiently, wound is clean and dry.
· Discharge home today
· Continue neck collar for 2 weeks
· Tabs nifedipine 30mg dly
· Tabs Zinnat 500mg 12hrly x 1/52
· Tabs metronidazole 400mg 8hrly x 1/52
· Tabs tramadol 50mg 12hrly x 1/52.
· Tabs HCT 50mg dly x 1/12
· Tabs telmisartan 80mg bd x 1/12
· Syr. Astymin10mls bd x 2/52
· Tabs pregabalin 75mg dly x 1/52
See in 2 weeks (01/08/2023) for out-patient follow up.
Kindly revert to us for further clarifications where necessary.
Dr. Ozoemena O.F
For team wellington clinics Abuja.