Case 3:18-cv-00347-CAB-MDD Document 253-15 Filed 01/18/20 PageID.22687 Page 1 of 6
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`EXHIBIT 15
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`TO THE DECLARATION OF BRIAN J. NISBET
`IN SUPPORT OF DEFENDANTS’ MOTION
`FOR SUMMARY JUDGMENT OR, IN THE
`ALTERNATIVE, SUMMARY ADJUDICATION
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`Case 3:18-cv-00347-CAB-MDD Document 253-15 Filed 01/18/20 PageID.22688 Page 2 of 6
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`1"'")(cid:173)
`~
`Scripps
`
`Scripps Memorial Hospital
`Encinitas
`
`OPERATIVE REPORT
`
`NAME:
`Date of Operation: 02/14/2017
`Diet Phys:
`NEVILLE ALLEYNE, MD
`Date of Birth:
`
`MED REC#:
`Room:
`Account#:
`
`-EE2W 2105/A
`
`SURGEON:
`Neville Alleyne, MD
`
`PREOPERATIVE DIAGNOSIS:
`L2-3, L3-4, L4-5, and LS-SI lumbar spinal stenosis with instability and scoliosis.
`
`POSTOPERATIVE DIAGNOSIS:
`L2-3, L3-4, L4-5, and LS-SI lumbar spinal stenosis with instability and scoliosis.
`
`PROCEDURE PERFORMED:
`Part 1: XLIF L2-3, L3-4, L4-5.
`
`ASSISTANT:
`Tommy D Hammonds, PA.
`
`ANESTHESIA:
`General endotracheal anesthesia.
`
`ANESTHESIOLOGIST:
`Dr. Ladan Farhoomandi, MD.
`
`Somatosensory motor evoked potentials being performed by Ms. Christina Brady.
`
`PROCEDURE IN DETAIL:
`The patient brought to the operating room, supine position. After successful general endotracheal
`anesthesia. Central line, A-line, Foley catheter, Venodyne boots, and somatosensory motor evoked
`potentials were placed. The patient was then meticulously placed onto the operating table in a lateral
`decubitus position with the right side up. All bony prominences well padded. Axillary roll was placed and
`the patient was then positioned for an XLIF and taped into position with a blanket roll on the anterior
`portion and posterior portion to keep her aligned. The bed was then flexed and appropriate AP and lateral
`x-rays were taken with fluoroscopy to obtain good end plates. Next the anterior longitudinal ligament,
`posterior longitudinal ligament, the 30 yard line and trajectory path were then marked at L4-5, L3-4, and
`L2-3. The wound was then prepped and draped in usual sterile fashion. The subcutaneous tissue was then
`infiltrated with 10 cc of Marcaine with epi. Incision was carried down through the skin down to the
`subcutaneous tissue. The fascia was then entered at L4-5 by using the Metz, blunt dissection down to the
`psoas. The surgeon's hand was then used to sweep and palpate the iliac crest, the TP as well as the disc
`space. The 1st dilator was placed and the thresholds were then checked and noted to be stable
`circumferentially, K-wire was then placed into the L4-5 30-yard line, followed by 2nd dilator which was
`tested and the retractor blades were then placed over the 2nd dilator and the lights were then inserted. The
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`OPERATIVE REPORT
`Page 1 of 3
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`HIGHLY CONFIDENTIAL-ATTORNEYS'
`EYES ONLY
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`ALLEYNE000013
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`Case 3:18-cv-00347-CAB-MDD Document 253-15 Filed 01/18/20 PageID.22689 Page 3 of 6
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`Squadron retractor was then opened and locked into position and secured with the bed mount. This was
`followed by the placement of the shim under AP fluoro at L4-5 followed by an annulotomy that was made
`after the K-wire and the dilators were removed and the floor of the disk space was then tested
`circumferentially for any thresholds. 15 blade was used to make a rectangular incision in to the anulus on
`the right side followed by pituitary rongeur to remove disc material and annular debris followed by the 4, 6,
`and 8 trial which were inspected under AP and lateral fluoro, the 8 trial was then used, we used an 8 x 18 x
`55 trial filled with DBM putty and BMP prior to placing are cage, the endplates were then scraped with the
`scrapper followed by the rasp. Pituitary rongeur was used to remove any further disc material and annular
`debris. The wound was then irrigated and suction dried and are 8 x 18 x 55 cage was then impacted with
`the impactor mallet. Intraoperative lateral x-ray continued our position. Because of the spondylolisthesis,
`care was taken to make sure where our posterior markers were, they were in good position and reduction of
`the spondylolisthesis was noted.
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`At L3-4 in the similar fashion, through the same opening the 1st dilator was placed and checked
`for threshold, K-wire was then placed at the 30 yard line and the 2nd dilator circumferentially
`tested and the retractor blades were then inserted. Once this was accomplished, the light was then
`turned on and the dilators were opened up with a Squadron retractor which was then locked to the
`bed mount and secured after the Squadron retractor blades were opened. The floor of the disc space
`was then tested and noted to have adequate threshold. The shim was then placed uneventfully
`followed by the annulotomy at L3-4 followed by pituitary rongeur to remove disc material and
`annular debris, followed by the 4, 6, 8, and 10 trials. The 10 x 18 x 55 trial was felt to be snug.
`Once this was removed and checked under AP and lateral fluoro, it was noted be in good position.
`This was followed by the scraper rasp disc space irrigation and the implant was then placed from
`Alphatec using the ____ impacted with the impactor mallet noted to be in good position and
`our attention was then taken to L2-3. In a similar fashion, at L2-3 through a separate incision
`skin incision was made. Subcutaneous tissue was visualized followed by the blunt dissection using
`the Metzenbaum scissors to the psoas at L2-3. The first dilator was placed and thresholds were
`tested, noted be adequate, K-wire was then introduced into the L2-3 disk space followed by the 2nd
`dilator which was checked circumferentially followed by the Squadron retractor blades being placed
`with the retractor uneventfully at L2-3 and opened after it was secured to the bed mount. Once this
`was accomplished, the 1st and 2nd dilators were removed, K-wire was left in place. The floor of the
`disc space was then tested circumferentially for adequate thresholds. The shim was then introduced
`at L2-3, secured, followed by the annulotomy which was done with a 15 blade followed by straight
`pituitary rongeur followed by the scraper and 4, 6, and 8 trials which were checked under AP and
`lateral fluoro, noted to have good threshold, once they were reintroduced, the 8 was felt to be
`adequate, we used an 8 x 18 x 50 filled with BMP and DBM putty. Impacted with the impactor mallet.
`Prior to doing this, the disc space at L2-3 was scraped, rasped, and further disc debris was
`removed followed by disc space irrigation and suctioning of that disk space. With the cage now in
`place L2-3 intraoperative AP and lateral fluoro confinned the position and orientation at all 3
`levels. The Floseal was then placed into each one of these openings and followed by lyophilized
`vancomycin. Fascia was closed with 1 Vicryl followed by the deep subcutaneous tissue with the 2-0
`Vicryl for both incisions. The incisions were then stapled. Dennabond and an Ioban dressing was
`then applied. Sponge and needle count were correct x2. The patient tolerated the procedure well. At
`no time were there any alterations in somatosensory and motor evoked potentials. Total blood loss
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`OPERATIVE REPORT
`Page 2 of 3
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`HIGHLY CONFIDENTIAL-ATTORNEYS'
`EYES ONLY
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`ALLEYNE000014
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`Case 3:18-cv-00347-CAB-MDD Document 253-15 Filed 01/18/20 PageID.22690 Page 4 of 6
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`about 50 cc for ____ combined 3 levels and at no time were there any alterations in somatosensory
`or motor evoked potentials. The 2nd part will be dictated after the patient is ___ _
`
`NEVILLE ALLEYNE, MD
`
`NA
`D: 2017-02-14 10:58:00
`T: 02/14/2017 20:29:54
`C:
`20170214731339491
`Confirmation No.: 20366483
`
`DICTATED BY:NEVILLE ALLEYNE, MD
`
`OPERATIVE REPORT
`Page 3 of 3
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`HIGHLY CONFIDENTIAL-ATTORNEYS'
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`ALLEYNE0000 15
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`Case 3:18-cv-00347-CAB-MDD Document 253-15 Filed 01/18/20 PageID.22691 Page 5 of 6
`+use s1e.1saa
`Scripps CONFIDENTIAL If arror, call:
`p. 1/3
`2017/03/13 16:41
`t◄ l
`
`C>
`S ...
`... crtpps
`
`Scripps Memorial Hospital
`Encinitas
`
`OPERATIVE REPORT
`
`NAME:
`Date of Operation: 02/14/2017
`NEVILLE ALLEYNE. MD
`Diet Phys:
`Date of Birth:
`
`MED REC#:
`Room:
`Account#:
`
`EDISC -
`
`SURGEON:
`Neville Alleyne, MD
`
`PREOPERATIVE DIAGNOSES:
`
`1. L2-L2, L3-L4, L4-L5, L5-S 1 decompressive laminectomy.
`2. Bilateral medial facetectomies at L2 to S 1.
`3. Bilateral foraminotomies at L2 to Sl.
`4. K2M instrumentation TIO to S2.
`5. Bilateral lateral fusion at T9 to S2.
`
`ASSISTANT:
`Mr. Tommy Hammonds.
`
`ANESfflESIA:
`General endotracheal anesthesia.
`
`ANESfflESIOLOGIST:
`Dr. Ladan Farhoomand. Somatosensory and motor evoked potentials being performed by Ms. Christine
`Brady.
`
`PROCEDURE IN DETAIL:
`The patient was brought to the operating room, supine position after successful general endotracheal
`anesthesia. Foley catheter had already been in place. Central line and A-line were already in place. The
`patient was taken from an excellent position and positioned on the operating table in Jackson frame for the
`posterior procedure. Care was taken moving the cervical spines so as to not cause a cervical spine injwy.
`All bony prominences were well padded. The upper extremities at 90:90 with padding under the ax.ilia to
`prevent brachia! plexopathy. Final position was then approved by Anesthesia.
`
`The patient was then prepped and draped in the usual sterile fashion. The subcutaneous tissue from TIO to
`S2 was infiltrated with 1: 500,000 epinephrine solution. Incision was carried down to the fascia. Fascia was
`then incised down to the spinolaminar junction further dissection out to the tips of the transverse process
`was accomplished using a Cobb and electrocautery dissection. Next, the supraspinous and interspinous
`ligaments at _____ were then removed. Next, the pins were placed into the TS spinous process and
`one pin at the posterior superior iliac spine on the right and the other on the left. The _____ was then
`assembled and the Mazor Renaissance robot was then called for.
`
`With the assembly of the _ _ _ __ , the AP and oblique registrations were then taken in the thoracic and
`
`OPERATIVE REPORT
`Page 1 of 3
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`HIGHLY CONFIDENTIAL-ATTORNEYS'
`EYES ONLY
`
`ALLEYNE000016
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`

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`Case 3:18-cv-00347-CAB-MDD Document 253-15 Filed 01/18/20 PageID.22692 Page 6 of 6
`p, 2/3
`[4]
`Scripp5 CONFIDENTIAL If error, call:
`+858 678.7500
`2017/03/13 16:41
`
`lumbar spine and sacral spine. After this was accomplished. the _____ had the robot attached and
`trajectories were then made from Tl O down to S2. Each screw was then drilled, tapped, and the screws
`were placed using the K2M instrumentation. The screws were pre-determined from our plan registration.
`With the screws now in placed, the decompression was then commenced.
`
`Using a _ _ ___ Smith-Peterson rongeur, the spinous process at L2. L3, L4, L5, and S1 were then
`removed, kept in _____ basin for later bone grafting. Redundant ligamentum flavum was then
`removed and bilateral partial medial facetectomies were then commenced using a high-speed on #3,
`#4, #5 _____ upbiting Kerrison rongeur followed by bilateral foraminotomies at L2, L3, IA, LS,
`and SI with #2 and #3 _____ Kerrison rongeur. The KW probe was then placed in the
`neuroforamen, it was without any impedance, and the wound was then irrigated with 3 L of bacitracin
`jet lavage. Once this was accomplished, the transverse process corresponding facet joints were then
`decorticated. Rods were then cut and contoured to a proper degree of sagittal contour. All screw
`heads were then tested and noted to have adequate _____ . Intraoperative AP and lateral x- ray
`was then taken to assess the alignment of our construct which appeared to be stable with adequate
`thresholds for all of our pedicle screws. The sagittal contour was then placed into the rods,
`engaged into the pedicle screws secured with interlocking nuts. The construct was then tightened to
`80 inch pounds of force with the corresponding distraction and compression done at the scoliotic
`level according to our plan. With the screws now all tightened, a cross connector was then placed
`in the thoracic spine and one in lumbar spine, secured. Gel-Foam was then placed over the dural
`tube after Ray-Tee sponge was removed. The Ray-Tee sponge was kept in place until bone graft was
`placed into the lateral gutter which started with the BMP, local bone. DBM putty and ___ _
`strips. Care was taken not to have any other bone graft material follow the exposed dural tube or
`nerve root sleeves to result in iatrogenic central or neural foraminal stenosis. After the Ray-Tee
`was removed, Gel-Foam was then applied over the dural tube. An 8-inch ConstaVac drain was brought
`through a separate stab incision. The wound was sprinkled with Lyophilized vancomycin. The deep
`fascia was then closed with #1 Vicryl. The subcutaneous tissue was then irrigated with another 3 L,
`sprinkled with Lyophilized vancomycin. The drain was also brought through a separate stab incision
`superolateral aspect of the wound on the right and closed with 2-0 Vicryl followed by the skin with
`skin staples. Dermabond sterile fluffs and ABD pad and Ioban dressing were then applied. The sponge
`
`OPERATIVE REPORT
`Page 2 of 3
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`HIGHLY CONFIDENTIAL-ATTORNEYS'
`EYES ONLY
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`ALLEYNE000017
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