Case Study: Posterior Spinal Fusion

L4-5 (Instrumented) with L3-5 decompression

The patient had been seen by us for an extended period of time with complaints of low back pain and pain radiating down to both legs, but more on the right side. He also had weakness in both lower extremities along with involvement of bladder. He had been seen by urology who was suggestive of it being of spinal origin.

Prior physical examination of the lumbar spine supported the diagnosis of lumbar canal stenosis. His imaging showed grade 1 to grade 2 spondylolisthesis with instability over L4-L5 with compression of nerve roots. There is also lateral recess compression at L3-L4 on the right and left side with compression of the traversing L4 nerve root.

We discussed treatment options in detail in the office as well as in the surgical holding area. We discussed infection, bleeding, possibility of CSF leak, injury to adjacent nerves and vessels, neurological deterioration, failure of implants, failure of healing, need for repeat surgery, need for antibiotics if anything gets infected, and the need for rehabilitation. We also discussed systemic complications including blood clots, cardiac, pulmonary or neurological complications including death.

Preoperative CT of Lumbar Spine
Preoperative CT of Lumbar Spine

The patient also understood and signed an informed consent to continue with the plan of decompression of L3-L5 along with an instrumented posterior spinal fusion of L4-L5.

The patient was taken to the operating room where general anesthesia was induced. The IV lines were secured. A Foley catheter was passed. Intraoperative neuromonitoring was put in place. The patient was turned prone on a four-post Jackson table with all bony prominences well padded.

Both shoulders were in a good position and well padded. The area of surgery was cordoned and cleaned and draped in the usual aseptic fashion. A time-out was called.

A midline incision was planned. The incision was carried deep into the spinous process and on either side of the spinous process with the help of bovie. The levels were checked. Further dissection was performed to expose the L3 and L4 lamina and the superior part of L5 lamina. The dissection was carried laterally to find the L4 and L5 transverse processes on either side.

Finally, it was decided to keep the median tension band intact and foraminotomy and laminotomy was performed on either side at L4 and L3 levels. The inferior facet of the L4 on the right side was removed to open the disc space.

The dura was unhealthy and thin and was having a lot of engorged vessels as well as scarring especially on the L4 level. The dura could not be separated easily. With the fear of durotomy and also it was found by the primary spin of the navigation arrow that the spondylolisthesis was well reduced that we decided not to perform the transforaminal interbody fusion.

The spin was performed by the navigation with the frame on. Once the dissection was done, we planned to find the screw holes first. Navigation probe followed by drill was used on the right and left L4 and L5 pedicles under navigation.

The screw holes were tapped. Pedicle probe was put in all the four holes. The screw was planned to be inserted in the end. Now, the decompression was further achieved on the right and left L3 and L4 laminectomies and foraminotomies leading to neurolysis of right and left L4 and L5 nerve roots.

In the process of decompression, there was incidental durotomy on the left L3 level. The durotomy was cordoned and secured. The nerve roots were put back into the thecal sac and primary closure of the durotomy was performed using Prolene #6-0. It was a watertight closure. A Valsalva maneuver was performed by increasing a pressure of 40 mm of HG and holding it for 20 seconds. There was no leak at that time.

Once that decompression was complete, the durotomy was sealed with the muscle flaps followed by DuraSeal and Surgicel in layers. Finally after the decompression, the screws were put in right and left L4 and L5 pedicles.

The transverse processes were decorticated using the bur on the right and left L4 and L5. A mixture of local bone with cancellous autograft with DBX and ViviGen was made and put into the lateral gutters between L4 and L5. The left L4-L5 facet joint was decorticated to allow fusion.

The wounds were thoroughly washed. Vancomycin 2 g was instilled into the wound. Surgical incision was closed in layers appropriately.

Bone marrow aspirate was also taken from the left iliac crest and mixed with the bone graft and was put into the lateral gutters. Final spin was taken with the navigation and found that the screws were in good place.

Once the closure was done, the patient was turned supine onto the bed. The patient was extubated. It was planned to send the patient to the floor with Foley in. The patient remained on bed rest for 48 hours.

Patient was followed in our office on regular intervals of 2 weeks, 6 weeks, 3 months and 6 months thereafter with gradual return of function. Physical therapy was also started. Patient did well postoperatively

Spinal Fusion of L4-L5
Spinal Fusion of L4-L5

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

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Dr. Karlkare and his staff were excellent. Dr. Karkare explained everything clearly and took his time getting to know my Dad.
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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.
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17:48 14 Jul 23
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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.
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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!!
Eclectic54
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!
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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.
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20:42 08 May 23
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15:02 02 Mar 23
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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.
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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
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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 .
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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❤️🙏🏼
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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.
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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
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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!
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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
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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.
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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
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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!!!
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17:26 17 Nov 20
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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.
Ryan
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
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My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.