PART ONE PROCEDURE PERFORMED:
1. Placement of Pivox PEEK cage (large) 12 mm tall, 16 deg at L5-S1 packed with Bio4 allogenic bone graft.
2. Placement on a large Medtronic Pivox titanium plate fixed with 25.0 mm and 25.0 mm Screws through plate over S1 and L5 bodies anteriorly
3. Placement of Pivox PEEK cage 8 mm tall x 55 mm wide, 6 deg into L34 packed with Bio4 allogenic bone graft.
4. Placement of Clydesdale PEEK cage 10 mm tall x 50 mm wide, 6 deg into L45 packed with Bio4 allogenic bone graft.
4. Total discectomy done anterior/obliquely at L3-L4, L4-L5 and L5-S1.

PART TWO PROCEDURE PERFORMED:
1. Posterolateral fusion performed, L3-4, L4-L5 and L5-S1 with placement of Bio4 allogenic bone graft at L3-L4, L4-L5 and L5-S1 facet joint complex.
2. Placement of Medtronic; Voyager system pedicle screws at the bilateral L3, L4 vertebral bodies of size 6.5 x 50 mm and placement of pedicle screws at the bilateral
S1 verterbal body of size 6.5 x 45 mm.
3. Attachment of 100 mm and 100 mm cobalt chrome rods on the left and right saddles of those pedicle screws, respectively.
4. Placement of temporary navigation reference frame in the left lateral iliac crest.
5. Intraoperative scan for O-arm navigation.
6. Intraoperative neuromonitoring

INDICATIONS:
XXXX is a XX y.o. male who I have been following in the office, who had had complaints of leg pain as well as back pain. he has tried nonoperative treatment including physical therapy
as well as a history of injections. Unfortunately, his relief of symptoms was not sustained with these conservative measures. As a result, imaging studies were reviewed. These showed
significant spondylosis at and degenerative disc disease at L3-L4, L4-L5 and L5-S1 with neuroforaminal stenosis at at each. he was given the option of nonoperative care and we discussed the implications
of a fusion. It was reiterated as well, that discogenic pain is difficult to diagnose. As a result of his condition, I gave him the opportunity to proceed with operative treatment of this condition. In no
uncertain terms have I indicated to the patient that this procedure would cure him of his symptoms. He signed a consent to proceed with surgery.

DETAILS OF PROCEDURE:
After informed consent was obtained, the patient was taken back to the operating room. he was placed under general endotracheal anesthesia. he was then placed in the left lateral decubitus
position with the left side up. The patient was then appropriately secured with tape. All bony prominences were well padded. A time-out was then facilitated in order to ensure this was the
correct patient, and that he was in the correct position, and the correct procedure was to be done. Then, his abdominopelvic region as well as his lumbosacral region were prepped and draped in
the usual sterile fashion. I and my assistant were gowned and gloved in the usual sterile fashion.

I began by initially placing a navigation reference frame in the left lateral and superior iliac crest. An intraoperative scan was then performed utilizing O-arm navigation system. After this scan was
performed, this allowed me and my co-surgeon to localize where the initial oblique incision was to be performed for an interbody fusions. Co-Surgeon, Dr. XXX, performed the oblique approach at L5-S1 and also exposed L4-L5 and L3-L4. He made a 6.5 cm incision with the use of 15-blade knife. I carried this incision through the various muscle plane while splitting them in an atraumatic fashion. We dissected in line through the abdominal muscles, and then identified the peritoneum and went through a retroperitoneal space. We identified and could see the lateral aspect of the lumbar disk spaces. The psoas muscle was lateral and was well protected at L3-L4, L4-L5, but at L5-S1 we approached between the bifurcation of the major vessels. After I identified this appropriate trajectory to the L5-S1 disk space and pinned and placed retractors at this level in order to protect the surrounding tissue, as standard discectomy was performed.

In the posterior space, I made an incision in line with the L3-L4, L4-L5 and L5-S1 lamina and facet joint complex. I sequentially dilated to an 18 mm Medtronic METRx tube system and, utilizing loupe
magnification, identified the lamina as well as the facet joint complex. I introduced a total of about 1.5 cc of Bio4 allogenic bone graft in total at both levels in order to attempt a posterolateral
fusion on this left side. With the posterolateral fusion having been completed, I then turned my attention to placement of the pedicle screws.

I made small stab incisions through the skin and the fascia and dilated to an appropriate size tube, and then introduced a 5.5 mm tap in and through the pedicle and into the vertebral body bilaterally
at L3, L4 and S1. Having completed the tapping for the screw, I then introduced the Medtronic 6.5 x 50 mm Voyager screws into bilaterally L4, L3 and 6.5 x 45 mm screws screws into bilaterally at the
S1 vertebral bodies. With those screws appropriately seated, I then turned my attention back to the anterior interbody approach.

We made an annulotomy through the disk space at L3-L4, L4-L5 and L5-S1. I then completed my diskectomy at those levels by removing the disk material in its entirety at each level. We then tried various size trial implants and settled on the placement of the following at each level.

1. Placement of Pivox PEEK cage (large) 12 mm tall, 16 deg at L5-S1 packed with Bio4 allogenic bone graft.
2. Placement on a large Medtronic Pivox titanium plate fixed with 25.0 mm and 25.0 mm Screws through plate over S1 and L5 bodies anteriorly
3. Placement of Pivox PEEK cage 8 mm tall x 55 mm wide, 6 deg into L34 packed with Bio4 allogenic bone graft.
4. Placement of Clydesdale PEEK cage 10 mm tall x 50 mm wide, 6 deg into L45 packed with Bio4 allogenic bone graft.

As each cage was deployed, this was done with the use of loupe magnification. With the cage in place, a little bit of Floseal was used to control any and all bleeding as well as a Surgicel. I removed all the
retractors. Prior to final closure, a final intraoperative o-arm scan was done confirming correct placement of all hardware. We determined that a 100 mm cobalt chrome rod and a 100 mm rod would be appropriately seated into the saddles of the pedicle screws on the left, and on the right respectively. This was introduced utilizing the voyager delivery system. With that rod deployed into the saddles of the pedicle screws, the rods were final tightened with the appropriate set screw. The towers of those pedicle screws were then removed.

I closed this oblique anterior abdominal wound initially with 2 Vicryl to reapproximate the fascia, 3-0 Vicryl to reapproximate the deep tissue, and then a running 4-0 Vicryl stitch. Steri-Strips were then applied and sterile Medipore dressing. I then turned my attention back to the posterior aspect. All incisions were then thoroughly irrigated. I did place approximately 20 cc of Exparel which had been diluted with 30 cc of normal saline in and around the musculature in the incisions. Closure was performed of the posterior incisions by initially closing the deep tissue with 3-0 Vicryl and reapproximating the skin and closing the skin with 4-0 running Vicryl stitch. Steri-Strips were also applied to these incisions as well and sterile Medipore dressing. The temporary navigation marker was also removed, and this was closed appropriately and sealed with a Medipore dressing.

He was then extubated in the operating in stable condition. All neuromonitoring returned back to baseline. he was transferred to the PACU in stable condition. At the end of the case, needle counts and
sponge counts were correct x2.