Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurosurgery

Surgery of the nervous system, including nerves, the brain or spinal cord.

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Hematoma Evacuation
Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion. Biopsy of dura.

Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure. She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.

Hemilaminotomy & Foraminotomy
Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.

Laminectomy & Discectomy & Facetectomy
Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP. Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.

Laminectomy & Facetectomy
Complete laminectomy, L4. and facetectomy, L3-L4 level. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System. Posterior spinal fusion, L4 to S1. Insertion of morselized autograft, L4 to S1.

Laminectomy & Foraminotomy & Cervical Fusion
Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5. Songer wire. Right iliac bone graft.

Laminectomy & Foraminotomy Revision
Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.

Laminotomy & Microdissection
L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.

Laminotomy, Facetectomy & Foraminotomy
Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots. Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots. Right L4-S1 posterolateral fusion with local bone graft. Left L4 through S1 segmental pedicle screw instrumentation. Preparation harvesting of local bone graft.

Lumbar Laminectomy
Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal. Lumbar stenosis and cerebrospinal fluid fistula.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples