Case Study: Transforaminal Interbody fusion

with Pedicle screw fixation of L5-S1

The patient who was seen in our office with complaints of left-sided radicular pain along with tingling and numbness. Aggravated by standing and walking. The patient was not able to perform usual activities of daily living let alone play sports.

The patient had a history of left-sided radiculopathy, which was treated with microdiscectomy in the past. The patient had tried conservative management in the form of NSAID’s, physical therapy, rest, but it did not help the patient.

Magnetic resonance imaging (MRI) was done, which showed previous left hemilaminectomy at L5-S1, Left central disc herniation/extrusion at L5-S1 contributes to effacement of the thecal sac and left lateral recess with severe spinal canal stenosis and mass effect upon the descending left S1 and at least S2 nerve roots.

We had discussed treatment options including; surgical and non surgical, both their risks, complications and recoveries. We discussed the use of implants in the form of screws, rods and cage as well as use of biologics such as bone grafts and substitutes from his own bone, cadaveric bone as well as non-human derivatives. We discussed the need for extensive rehab, inability to return to presurgical level among others. Patient agreed with the plan which was a Transforaminal Interbody Fusion (TLIF) L5-S1 electively.

The patient was taken to the operating room where general anesthesia was induced and a Foley catheter was passed. Preoperative antibiotics in the form of 2g of Ancef was done, which was repeated after 4 hours of surgery. The patient was flipped prone on a four-post Jackson table.

All the bony prominences were well padded. The lower back was prepped and draped aseptically in the usual fashion. Time-out was called. He had a scar, which was on the left side of the midline.

Incision was given along the right margin of the scar towards the midline. The incision was extended deep through the subcutaneous tissue and the fascia. The spinous process was reached and dissection was done on either side of the spinous process of presumed L4, L5, and S1.

Dissection was taken down to the lamina on the right side of L4 and L5 and a Woodson was inserted underneath the lamina of presumed L5. X-ray was taken in lateral view and found that the Woodson was under the L5 lamina.

The level was marked and further dissection was performed on either side of L5, inferior L4 and the superior part of the S1 to the facet joint of L4-5 and L5-S1 on either side. Further dissection was done along the transverse process of L5 and sacral ala on either side.

Once the dissection was done, the decision was made to put pedicle screws in both pedicles of S1 and L5. Drill was used to mark a pilot hole and a gearshift was used to guide the hole through the pedicle of S1 on either side under fluoroscopic guidance. Ball-tip sound was used to check the integrity of the canal.

Then 40 mm x 6 mm of pedicle screws (Depuy Synthes) were inserted on either pedicle of S1 and checked under fluoroscopy and found to be in satisfactory position. Similarly, a pilot hole was made with the use of drill on either side of the pedicle of L5 followed by a gearshift to find the path under fluoroscopy. A ball-tipped probe was again used and all the walls were found to be intact. Again, tapping was done and 6 mm x 45 mm pedicle screws were inserted in either pedicle.

Now the laminectomy of L5 was performed on either side with the use of kerrison punches and match stick burr. Pars was left intact on the right side, but the pars was excised on the left side with the use of burr and an osteotome. The superior facet of the S1 was also removed with the use of Kerrisons. Multiple large disc fragments were removed from the left S1 foramen to decompress the nerve.

A laminectomy and decompression of bilateral L5 and S1 was performed with kerrison punches and checked with a woodson probe. Discectomy of the L5-S1 was done on the left side with the use of curettes, shaver, and pituitary.

A trial cage was inserted and checked under fluoroscopy and it was decided to put a 9 mm x 36 mm titanium cage. Allograft was used and mixed with morselized auto bone graft of the lamina and spinous process. The cage and disc interspace was filled with bone graft and the cage was inserted and checked under fluoroscopy, found to be in satisfactory position.

A thorough irrigation of the wound was done and decortication of the transverse process of both L5, sacral ala as well as parts on the right side was performed and bone graft was inserted over the Fibergraft. The 45-mm rods were used to connect the both pedicle screws on either side and the set screws were inserted and tightened and torqued.

Final pictures were taken and saved. Surgiflo mixed with 40 mg Solu-Medrol was put over the exposed dura. In the process of decompression, there was patch of ligamentum flavum, which was stuck to the dura or left as an island as it was very risky to remove it. The nerve roots were thoroughly decompressed. Hemostasis was achieved.

The wound closure was performed in the layers by the plastic surgeon and was dictated separately. Two grams of Ancef was repeated after 4 hours of surgery. The patient was extubated and moved to the postoperative recovery unit in a stable condition.

Postoperative X Ray showed there is a normal lumbar lordosis. There were no destructive abnormalities or fractures. The intervertebral disc spaces appear preserved. There was no spondylolisthesis. The facet joints appear unremarkable.

The patient followed up in our office two weeks after the surgery, with their post operative images. During this visit we discussed home exercise programs for rehabilitation of the back. We went over the X Rays and the surgical procedure. They agreed to continue icing to keep the swelling to a minimum and to continue to utilizing early mobilization and mechanical prophylaxis to reduce the chances of a deep vein thrombosis.

They will lean themselves off any narcotic medications and progress to anti-inflammatories and Tylenol as long as there are no contraindications to these medications. In their last office visit the patient stated their radiculopathy had been resolved.

They were able to perform all usual and recreational activities and were also able to exercise. They were able to do 40 pushups, run 1.5 miles in 15 min and plank for 1.5 minutes.

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

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5.0
Based on 106 reviews
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.
Dave
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!
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.
Sam
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.
Ryan Brigandi
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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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.