Surgery Report

SPINE DIVISION
June 28th, 2019

Andra Hendriarto
M Ade Refdian Menkher
Uno Surgery Erwin
Ido Prabowo
 Asih Purnamawati, Female, 26 y.o, 395-76-79, JKN
Dr. dr. Rahyussalim, SpOT(K)

Diagnosis Performed
Bone defect of Th9-10
post posterior stabilization - Thoracotomy
of Th8-L1 due to - Stem Cell application
Spondylitis TB frankel C

Implant -
Vendor -
EPI -
Duration of surgery 2 hours
Blood -
Preoperative condition
 Intraoperative

Draping left chest Left thoracotomy approach

Distal Proximal
 Intraoperative

Exposed of anterior Th9-

Left thorax Exposed
Th10

Distal Proximal
 Intraoperative

Bone defect at anterior Th9- UC MSC implantation

Th10

Distal Proximal
 Intraoperative

Thoracic catheter insertion Wound closure

Distal Proximal
 Comparison xray

Preoperative Post operative

Distal Proximal
Ms. Riska WindaYuliani, female, 27yo, 437-96-23, JKN
Attending : dr. Ifran Saleh, SpOT(K)

Diagnosis Performed
• Back pain due to Total Treatment VI:
spondylitis Tb Th12-L1 • Debridement
Frankel E with right
psoas abscess • Posterior stabilization
of Th11, Th12, L1, L2
• Iatrogenic dural tear
• Dural repair

Implant Pedicle screw, rod, nut, crosslink

Vendor GS
EPI 40 millions
Duration of surgery 3 hours
Blood PRC 250cc
Pre Operative Condition
 Intraoperative

Leveling at level Th12 before

Drapping and Design incision

Caudal Cranial
 Intraoperative

First Incision Exposed of Th12, L1, L2

Caudal Cranial
 Intraoperative

Leveling Image intensifier view

Caudal Cranial
 Intraoperative

Pedicle screw insertion Dural tear at level Th12

Caudal Cranial
 Intraoperative

Dural repair Distraction

Caudal Cranial
 Intraoperative

Final construct Abscess evacuation

Caudal Cranial
 Intraoperative

Sinus track exposed Wound Closure

Caudal Cranial
Comparison between Pre and Postoperative XRay

Preoperative Post Operative

Mrs. Dini Haryanti, Female, 44 y.o, 339-86-24, JKN
Attending : dr. Dohar Tobing, SpOT(K)
Diagnosis Performed
• Back pain due to Spondylitis • Anterior debridement
TB of Th4-Th5, Th10-Th12 through transpedicular
Frankel D • Transpedicular biopsy
• Posterior stabilization of
Th3-Th4 and Th6-Th7

Date of
operation
Date of Surgery Juni 27th 2019

Implant Pedicle screw, rod, nut,

Vendor Patriot
EPI 73 Million
Duration of surgery 5 hours
Preoperative Condition
 Intraoperative

Drapping Leveling at Th5

Caudal Cranial
 Intraoperative

First incision Exposed

Caudal Cranial
 Intraoperative

Leveling Image intensifier view

Caudal Cranial
 Intraoperative

Pedicle screw insertion Transpedicular biopsy

Caudal Cranial
 Intraoperative

Transpedicular debridement

Caudal Cranial
 Intraoperative

Rod insertion Final Construct

Caudal Cranial
 Intraoperative

Wound Closure

Caudal Cranial
 Comparative Xray

Preoperative Postoperative

Patient was still in ICU

 Surgery Report

SPINE DIVISION
June 28th , 2019

Preoperative
 Mr. Sigit Pradana, 23yo, 439-09-27, JKN
Attending : dr. Dohar AL Tobing, SpOT(K)
Chief complaint
Weakness on his both leg since 2 weeks ago

History of present illness

• Patient complained of weakness on his both leg since a month ago. The patient also
complained of back pain, that was sharp and did not radiate. It aggravated by activity. He
still could do daily activity normally at that time.
• There was numbness and tingling sensation. He is still able to walk
• Since 2 weeks ago, he felt weakness on his both leg and caused him fall from the
motorcycle
• There was no history of trauma
• There was no history of prolonged cough and no history of loss of bodyweight
• There was history of intermittent fever and sweating at night
• He was treated using ATB drug since 2 days ago
• Normal defecation but he cannot hold urinate

History of past illness

DM (-), hypertension (-)
 General State
Compos mentis, vital signs within normal limits

Head : no deformity
Eye : anemic conjunctiva (-), icteric sclera (-)
Neck : no lymph enlargement
Lung : vesicular +/+, rhales -/-, wheezing -/-
Heart : heart sound I-II normal, murmur (-),
gallop (-)
Abdomen : No pain on palpation, liver and spleen
normal, no muscular defense, normal
bowel sounds
Extremity : warm, CRT <2”
 Local state of the back

Look : Deformity (+), gibbus (-), sinus (-)

Feel : Midline tenderness at thoracal region VAS 2-3,
sensoric Th4-L1 1/1, L2-S1 1/1
Move : ROM spine normal, Motoric L2-S1 1/1
 Neurological
Right Left
Examination
C5 5 2 2 5 C5

Motoric
Motoric
C6 5 2 2 5 C6
Reflexes Right Left C7 5 2 2 5 C7
C8 5 2 2 5 C8
Patellar +++ +++
Tendon (L4) T1 5 2 2 5 T1
Achilles +++ +++ T2 2 2 T2
Tendon (S1)
T3 2 2 T3
Babinsky + + T4 1 T4
Group 1
Clonus + + T5 1 1 T5
T6 1 Sensory 1 T6

Sensory
Autonom T7 1 1 T7
Urinary Incontinence (+) T8 1 1 T8
Fecal Incontinence (-) T9 1 1 T9
T 10 1 1 T 10
T 11 1 1 T 11
T 12 1 1 T 12
L1 1 1 L1
L2 1 1 1 1 L2
Motoric

L3 1 1 1 1 L3

Motoric
L4 1 1 1 1 L4
L5 1 1 1 1 L5
S1 1 1 1 1 S1
 Pre operative X-ray

Alignment :
Local Kyphotic on thoracal region

Bone :
Decreased vertebral body height of
Th6 with anterior destruction

Cartilage :
Destruction of superior and inferior
endplate Th4-Th5, Th5-Th6

Disc :
Narrowing disc space Th4-Th5, Th5-
Th6
MRI Sagital T2 of thoracal
MRI Axial T2 of thoracal
MRI Coronal of thoracal
 Laboratory Examination
Laboratory Result Normal Range
Complete Blood Count
• Hemoglobin 14.7 13.0 – 16.0 g/dL
• Hematocrit 43.3 40.0 – 48.0 %
• Leucocyte 22.170 5.0 – 10.0 (10^3 uL)
• Platelet 225.000 5.0 – 10.0 (10^3 uL)
• ESR 15 0-20
ALT (SGPT) 283 < 41 U/L
AST (SGOT) 43 < 37 U/L
Ureum 45 19.0 - 44.1 mg/dL
Creatinin 0.7 0.80 - 1.30 mg/dL
Billirubin total 1.04 0.2– 1.2 mg/dL
Billirubin Indirek 0.53 0.0 - 0.5 mg/dL
Billirubin Direk 0.51 0.2 - 0.8 mg/dL
 Mr. Sigit Pradana, 23yo, 439-09-27, JKN
Attending : dr. Dohar AL Tobing, SpOT(K)

Diagnosis Plan to perform

• Paraparesis due to Total Treatment VI:
spinal cord • Basic Treament of TB
compression due to • Transpedicular
Spondylitis TB of Th 4- debridement
Th5 with paravertebral • Decompression
abscess
• Posterior stabilization Th3-
List of problem: Th4, Th6-Th7
• Infection
• Pain Implant Pedicle screw, rod, nut, crosslink,
meshcage
• Instability
Vendor Patriot
• Abscess
EPI 40 millions
• Deformity
Duration of surgery 4 hours
• Pathological fracture
Blood PRC 250cc
Mrs. Triana Fauziah, female, 27yo, 438-35-08, JKN
Attending : dr. Dohar AL Tobing, SpOT(K)

Chief complaint
Back pain since 2 months ago

History of present illness

• Patient complained about back pain since 2 months ago. The pain was sharp and did not
radiate. It aggravated by activity. She still could do daily activity normally at that time.
• She is still able to walk
• There was no history of trauma
• There was no history of prolonged cough and no history of loss of bodyweight
• There was no history of intermittent fever and sweating at night
• Normal defecation and urinate

History of past illness

DM (-), hypertension (-)
 General State
Compos mentis, vital signs within normal limits

Head : no deformity
Eye : anemic conjunctiva (-), icteric sclera (-)
Neck : no lymph enlargement
Lung : vesicular +/+, rhales -/-, wheezing -/-
Heart : heart sound I-II normal, murmur (-),
gallop (-)
Abdomen : No pain on palpation, liver and spleen
normal, no muscular defense, normal
bowel sounds
Extremity : warm, CRT <2”
 Local state of the back

Look : Deformity (-), gibbus (-), sinus (-)

Feel : Midline tenderness (-), step off (-)
Move : ROM spine normal
 Neurological
Right Left
Examination
C5 5 2 2 5 C5

Motoric
Motoric
C6 5 2 2 5 C6
Reflexes Right Left C7 5 2 2 5 C7
C8 5 2 2 5 C8
Patellar ++ ++
Tendon (L4) T1 5 2 2 5 T1
Achilles ++ ++ T2 2 2 T2
Tendon (S1)
T3 2 2 T3
Babinsky + + T4 2 T4
Group 2
Clonus + + T5 2 2 T5
T6 2 Sensory 2 T6

Sensory
Autonom T7 2 2 T7
Urinary Incontinence (-) T8 2 2 T8
Fecal Incontinence (-) T9 2 2 T9
T 10 2 2 T 10
T 11 2 2 T 11
T 12 2 2 T 12
L1 2 2 L1
L2 5 2 2 5 L2
Motoric

L3 5 2 2 5 L3

Motoric
L4 5 2 2 5 L4
L5 5 2 2 5 L5
S1 5 2 2 5 S1
 Pre operative X-ray

Alignment :
Normal alignment

Bone :
No vertebral body destruction,
hiperdensity on L2 vertebral body

Cartilage :
Destruction of superior endplate
Th1-Th2

Disc :
No Disc narrowing
MRI Sagital T2 of lumbar
MRI Axial T2 of lumbar
 Laboratory Examination
Laboratory Result Normal Range
Complete Blood Count
• Hemoglobin 14.2 13.0 – 16.0 g/dL
• Hematocrit 41.7 40.0 – 48.0 %
• Leucocyte 7.930 5.0 – 10.0 (10^3 uL)
• Platelet 411.000 5.0 – 10.0 (10^3 uL)
• ESR 12 0-20
• CRP 8.2 < 41 U/L
Mrs. Triana Fauziah, female, 27yo, 438-35-08, JKN
Attending : dr. Dohar AL Tobing, SpOT(K)

Diagnosis Plan to perform

Back pain due to susp. Transpedicular biopsy
Primary bone tumor DD/
Spondylitis Tb

Implant -
Vendor -
EPI 10 millions
Duration of surgery 2 hours
Blood -