Case Study: L4-S1 Posterior Instrumented Fusion

with L5-S1 Transforaminal Lumbar Interbody fusion

with Osteotomy

The patient presented to outpatient clinic status post motor vehicle accident with signs and symptoms of lumbosacral spondylolisthesis, bilateral L5 spondylolysis, L5 compression fracture, severe compression of L5 nerve root, and clinically with foot drop, severe radiculopathy and back pain. Surgery was recommended to decompress and stabilize the lumbosacral spine.

The risks, benefits, alternatives and potential complications were explained to him. All questions were answered until no further issues were raised. He was provided written and informed consent.

The patient was brought to the operating room. Their identity was verified. General anesthesia was induced, and they were intubated by the anesthesia service. Respiratory and cardiac monitoring leads were placed.

Neuromonitoring leads for somatosensory evoked potential and EMG were placed, and baseline signals were obtained. Foley catheter was placed, which was difficult to pass. They received preoperative prophylactic IV antibiotics and tranexamic acid via IV infusion for hemostasis.

She was positioned prone on the Jackson Relton-Hall frame. All pressure points were carefully padded. Lumbar area was prepped, cleaned with chlorhexidine. A 23-gauge spinal needle fluoroscopy was localized at L5-S1. Skin was sterilized with DuraPrep solution.

A midline incision was demarcated. Sterile drapes were placed in the usual manner. 1% lidocaine with epinephrine was infused.
Skin was opened with a 10-blade scalpel. Hemostasis was obtained with a bipolar electrocautery.

Bovie monopolar was used to carry the incision down through the midline subcutaneous tissues sharply dividing the fascia, and subperiosteal dissection with Bovie and Cobb elevators were performed exposing posterior elements of the spine at L4, L5, and S1 including bilateral transverse processes of L4 and L5, and bilateral S1 ala. During exposure, there was a small incidental durotomy noted at S2-S3 level.

Exploration was performed with curettes and there was a midline sacral defect where the durotomy occurred. This was repaired primarily with a single 4-0 Nurolon stitch and DuraSeal without any further cerebrospinal fluid leakage or issue apparent.

Valsalva maneuver was apparent to verify adequate repair. Next, self-retaining retractors were placed. Woodson elevator was placed under the L4 lamina.C-arm unit was draped sterilely and brought to the field, needed to confirm the level.

Schanz pins were placed in the right posterior superior iliac crest after infusing local anesthesia and creating stab incision with a 15-blade scalpel. The Schanz pins were placed. Neuronavigation was arrayed.

The patient was draped sterilely. Intraoperative CT scan was obtained and the data was transferred to the neuronavigation computer. Accuracy was verified and neuronavigation techniques were used to place pedicle screws in the L4, L5, and S1 pedicles bilaterally.

We began decorticating with an electric high-speed drill and Leksell rongeur, cannulated the pedicles of L4 bilaterally with the navigated pedicle finder, palpated for breaches and measured the depths. We used a 5.0-mm tap and placed 6.0 x 45 mm titanium pedicle screws using navigation without difficulty.

Next, we placed the bilateral S1 pedicle screws in the same manner using neuronavigation techniques. Four starting points and trajectory identification, cannulation of the sacrum, we palpated, we under tapped by 2-mm using 5.0 tap and then we placed 7 mm x 40 mm screws without difficulty. Neuromonitoring signals were stable. We did not put the L5 screws at this point.

We began the laminectomy and decompression. We began with the L5 decompression, bilateral pars defects were identified as per the preoperative imaging. Leksell rongeur, Kerrison rongeurs, and electric high-speed drill were used to perform L5 laminectomy and facetectomy was performed which was complete on the left side including the inferior articular process and the superior articular process.

Epidural bleeding was controlled with bipolar electrocautery, surgical hemostatic matrix, and thrombin-soaked Gelfoam.n Copious amounts of sterile irrigation were used throughout the procedure. The L5 nerve root was identified, completely neurolyzed with Kerrison rongeurs and nerve hooks then confirmed with Woodson elevator.

In order to access the L5-S1 disc space, we had to remove the entirety of the L5 and S1 facet on the left side, part of the pedicle, and performed L4 laminectomy.

Nerve root retractor was used to retract thecal sac and S1 nerve root medially towards the patient’s right side. Due to the spondylolisthesis and collapse, which appeared to be worse on the CT scan with bone-on-bone. We had to perform resection of sacral promontory on the left side exposing with Bovie using Kerrison rongeurs and osteotomy to pass through the posteroinferiorly corner of the L5 body, which was collapsed on the sacral endplates.

We used sequential paddle shavers to distract L5-S1 and perform a discectomy. Residual disc material was removed with pituitary rongeurs. Curettes and rasps were used to decorticate the L5 and S1 endplates.

The interspace was irrigated clear. Morselized autograft was packed in the interspace, and then a titanium 22-mm long expandable interbody spacer was gently tamped into the interspace with a mallet. AP and lateral fluoroscopy was performed to confirm midline positioning and depth; the cage was expanded to the appropriate tightness and tight.

X-rays were repeated to confirm correct positioning and size. Neuromonitoring signals were stable. Next with the left L5 pedicle completely isolated and exposed, we placed left L5 pedicle screw decorticating with electric high-speed drill cannulating with the curved freehand Lenke pedicle finder palpating for breaches using 5.0 mm tap and placing 45 mm x 6.0 diameter titanium pedicle screw without difficulty.

We then similarly placed a right L5 pedicle screw as well using similar technique. We draped the patient sterilely and obtained an intraoperative CT scan which showed correct positioning of all the pedicle screws and interbody spacer.

Subsequent to that, we decorticated the bilateral L4-L5 transverse processes and sacral ala for arthrodesis using electric high-speed drill. We confirmed hemostasis with Aquamantys and bipolar. We irrigated the wound clear.

Precut and precontoured titanium rods were selected and placed across the tulips and secured with locking caps, which were all final tightened with torquing and anti-torque devices at L4, L5 and S1. Morselized demineralized bone matrix autograft collected from the decompression as well as bone morphogenic protein allograft were packed into the lateral gutters from L4 to S1 to the posterolateral arthrodesis.

We took final AP and lateral x-rays, which showed correct positioning of all the hardware. The closure will be dictated separately. At the end of the case, the patient was turned supine on the cart, and transported to the recovery room in stable condition.

All sponge counts, needle counts, and instrument counts were correct, and the patient tolerated the procedure well with 250 mL of estimated blood loss. No complications aside from very small incidental S2 approximate level durotomy repaired primarily.

The patient followed up 10 weeks after the surgery for a routine postoperative visit with no complications or signs of infection. Since then the patient has been able to return to their daily activities. Severe radiculopathy and back pain has improved along with no more foot drop syndrome observed.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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I had an extremely friendly and personalized medical consult with Dr Karkare. Dr Karkare was very knowledgeable and very professional. His communication skills was extremely good and explained my medical condition in very simple words. The office visit was very helpful in understanding my medical condition. Thank you Dr Karkare
Padmanabhan Nagaraj
20:49 25 Sep 23
Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
Anna Acker
22:46 07 Sep 23
Dr Vedant Vaksha had done emergency surgery in 2020 after a traumatic injury.His office at Complete Orthopedics handled the continued care thereafter.Dr V and his staff had been Professional and friendly throughout the process, taking the time to explain all the questions on how to proceed and what to expect.Whenever I needed to speak with Dr V or the office they were a phone call away, without waiting or calling several numbers like in so many other medical offices.The office was accommodating to scheduling to my needs at all times. Dr Vedant Vaksha earned the following5 out of 5 stars, highly recommended.
John Kuey
20:58 05 Sep 23
Dr. Vaksha helped me recover from an injury. I am very thankful that he took the time to explain the best treatment for my injury. Also thankful for the wonderful office staff!
Joseph Castelli
22:30 02 Aug 23
The office is wonderful!… Dr Paresh was very helpful and attentive and made my sister in laws recovery so much better.. Thank you for everything
Jazz Lorenzo
17:48 14 Jul 23
The ladies are very welcoming, the service is great, the doctor is very professional and caring and the building is super clean. I really like to come here, the atmosphere is very friendly... Come and you will love it too.
Joan Carasco
14:41 30 Jun 23
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.