70 Ridge Road, 2nd Floor, Lyndhurst, New Jersey 07071

P (201) 504-1400 • F (201) 340-4313

OPERATIVE REPORT

PATIENT NAME: Zuleyka Garcia

DATE OF BIRTH: 02/19/1967

DATE OF OPERATION: January 8, 2024

PREOPERATIVE DIAGNOSES:
1. C4-5 disc herniation
2. C4-5 stenosis
3. C4-5 cervical radiculopathy
4. Intractable neck pain

POSTOPERATIVE DIAGNOSES:
1. C4-5 disc herniation
2. C4-5 stenosis
3. C4-5 cervical radiculopathy
4. Intractable neck pain

SURGEON: Grigory Goldberg, M.D.

ASSISTANT: Tony Jacob, P.A. whose assistance was required for retraction, exposure, instrumentation,
protecting vital structures and closure.

OPERATIVE PROCEDURES:
1. Complete anterior cervical discectomy and fusion, C4-5, removal of vertebral uncinate process bone
and endplate preparation, bilateral foraminotomy with root decompression. #22551
2. Interbody Cage, 7x15x12 and screws 4 (4x12mm) C4-5. #22853
3. Anterior 12mm Cervical Plate at C4-5. #22845
4. Harvesting and placement of allograft and autograft #20936 #20930

ANESTHESIA, MONITORING AND POSITIONING: General Endotracheal, Supine with Full SSEP and EMG
Monitoring
Zuleyka Garcia
01/08/2024

BLOOD LOSS: Minimal

COMPLICATIONS: None.

INTRUMENTATION:
1- 12mm Zavation Cervical Plate
1- 7*15*12mm Captiva Porous Cage
4- 4.0*12mm self tapping screws

INDICATION FOR SURGERY: The patient is a pleasant 56-year-old female who was injured in a motor vehicle
accident. This happened on October 26, 2021. The patient was a seat-belted driver of a car that was
sideswiped on the driver side by a New Jersey transit bus that was attempting to merge into the patient's
lane. As per the patient, the airbags did not deploy. The patient states that she did have a positive loss of
consciousness. After the car accident, she was evaluated by EMT, but she drove herself to New Bridge
Medical Center where she actually works and that is why she went there and there she was evaluated by the
physicians in the emergency room. She was subsequently discharged. Since the injury, the patient states
that she has pain in the neck going down her arms with numbness and tingling. The pain level is 10/10. She
underwent physical therapy and chiropractic treatment with Dr. Karl Nixdorf with minimal benefits. She also
underwent pain management. She underwent epidural injection at C5-6 level on September 6, 2022. The
symptoms have not gotten better. The pain is increased with activity and not relieved by rest. Almost any
activity causes the pain. It is getting progressively worse. She works in medical assistance and it is hard for
her to work or do any activities.

Diagnostic Studies: The patient had MRI of the cervical spine done on July 14, 2022. The MRI showed the
patient had a cervical disc herniation with stenosis at C3-C4, C4-C5, C5-C6, and C6-C7.

New MRI done on September 13, 2023, showed specifically at C4-5 there is annular tear and midline cervical
disc herniation resulting in spinal stenosis compressing the ventral cord and bilateral lateral recess narrowing.
At C5-C6, there is a broad-based posterior disc bulge and at C6-7 there is no evidence of any tear or cervical
disc herniation.
The patient had a discogram done on September 13, 2023, which was positive for C4-5 level with grade 4
annular tear and severe concordant pain from C4-5 level.

Physical Examination: The patient has limited range of motion of the cervical spine. She has 4/5 bilateral
deltoid and biceps. Her triceps and wrist extensor is 5/5. The patient states that she has decreased
sensation in right C5 and C6 dermatomal distribution. On the left side, sensation is intact. The patient has
positive Spurling bilaterally. Deep tendon reflexes are intact.

Impression:
1. Cervical disc herniation C4-5.
2. Cervical radiculopathy C4-5.
3. Cervical stenosis C4-5.

Treatment Plan: The patient is a pleasant lady who was injured in a motor vehicle accident. This happened
on October 26, 2021. Since then, she has pain in the neck going down her arms. It is getting progressively
worse. She underwent physical therapy with no relief. She underwent epidural injection with no relief. She
had MRI of the cervical spine done on January 4, 2022. A new MRI done on September 13, 2023, shows
progression of the C4-5 cervical disc herniation with annular tear indicating acute pathology from a recent car
Zuleyka Garcia
01/08/2024

accident. The pain has gotten progressively worse. This is despite physical therapy and epidural injection. At
this point, my recommendation was for surgery.

Surgery today was anterior cervical discectomy and fusion at C4-5. CPT codes: 22551, 22845, 22853, 20936,
20931.

PERMANENCY AND CAUSALITY: Ms. Garcia’s permanent cervical injuries including disc herniation,
radiculopathy, and need for surgical intervention is causally related to the October 26, 2021 accident with a
reasonable degree of medical probability.

DESCRIPTION OF THE PROCEDURE: The patient was brought to the holding area, surgical site was
marked. The patient was brought to the operating room and anesthesia was applied. The patient was
positioned on OR table and all pressure points were well padded. The skin was cleansed and scrubbed with
Betadine and sterile drapes were applied. Preoperative antibiotics were given. At this time, SSEP and MEP
was obtained. Once the antibiotics were given, time-out was called. A midline incision was made on the
right side above the prior incision. A standard Smith-Peterson approach was used. The platysma muscle was
identified and transected. The deep fascia interval was developed superiorly, inferiorly, medially, and
laterally. The prevertebral fascia was identified and dissected.

The disc C4-5 space was identified counting up from T1 and down from C2 and marked with pen above. A
spinal needle was placed in the disc space above at C4-5. X-ray was obtained and confirmed that this was
C4-5 level which was unstable and herniated.

Throughout this entire case care was taken to avoid injury to the trachea, the esophagus, the laryngeal
nerves and the major blood vessels. There were no apparent complications throughout this entire case. I
identified the C4-5 disc space carefully visually and with x-ray.

Subsequently attention was turned to removing the C4-5 disc which was carefully and safely
identified. Longus colli muscles was dissected subperiosteally and retractor was placed beneath the longus
colli muscle. Anterior bone and endplate at C4-5 was identified and taken down with a Kerrison. The disc
was entered with #15 blade. Complete discectomy was carefully and meticulously performed using pituitary
and curettes. The visualized and now extravasated and extruded disc herniation was completely removed
with pituitary. The PLL was entered and then was carefully removed as well. The PLL was taken down with
#1 Kerrison. The herniation appeared to be compressing the C5 nerve root and on direct visualization appear
as it appeared on the MRI imaging. The spinal canal and foramena and uncinate process bone at C4-5 were
safely and adequately decompressed with a complete discectomy using burr, pituitaries and curettes. A
partial corpectomy and bilateral uncinate bone resection in addition to complete discectomy was required
due to the position of the herniation on the right and this was done safely and carefully with burr and
curettes. At this point, Valsalva maneuver was performed, which showed no evidence of any dural tears
checking repeatedly. All bleeding was controlled and the area was measured to accept a 7x15x12 Captiva
Porous cage from Icon Medical, which was packed with autograft and allograft and impacted into place after
the endplates were prepared with a Midas-Rex and Kerrisons. Autograft had been obtained from the
decompression.

After the interbody prosthetic spacer with graft bone was applied, safely and carefully tamped into perfect
place- a 12mm Zavation cervical plate was applied and secured with screws, two 4x12 mm screws from Icon
Medical in C5, two 4x12 mm screws from Icon Medical in C4. AP and lateral x-ray obtained showing excellent
position of all instrumentation. The MEP and SSEP was obtained and showed no change from baseline. I
Zuleyka Garcia
01/08/2024

carefully and finally inspected the great vessels, trachea, and esophagus and found no injury whatsoever.
Care was taken to avoid injury to the laryngeal nerves. A drain was placed after repeated and thorough
gentle irrigation. The platysma was closed with 2-0 Vicryl and the skin was closed with subcuticular 3-0
Vicryl. The patient was transferred to recovery in stable condition with no complications noted and no new
or evolving neurologic changes.

Digitally signed by
Grigory Goldberg,
M.D.
Date: 2024.01.09
09:39:23 -05'00'
_______________________
Grigory Goldberg, MD
01/08/2024