# Help with TLIF codes



## nkrush12 (Sep 23, 2009)

I am at a loss here! Any help would be appreciated

Pre-Operative Diagnosis: 1. T8-T9 calcified herniated disc
                                           2. myelopathy.
Post-Operative Diagnosis: 1. T8-T9 calcified herniated disc
                                            2. T8-T9 intradural herniated disc.

*Procedure: 1. T8-T9 bilateral transcostal/transpedicular approach for discectomy.
                   2. Intradural resection of T8-T9 herniated disc.
                   3. T8-T9 TLIF
                   4. T7-T10 posterior lateral instrumentation.
                   5. T7-T10 posterior lateral arthrodesis.*


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## BCrandall (Sep 23, 2009)

A TLIF is for lumbar spine so you can't use that. Can you post the op note? I'm confused as to what was done at which level(s)...


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## nkrush12 (Sep 29, 2009)

DESCRIPTION OF PROCEDURE
Having appropriately positioned her, we then prepped and draped her back in the appropriate fashion. We marked off levels of her spine with spine needles for marking over the top of the pedicle facet complexes, and localized her incision using C-arm guidance. The skin was marked with a midline incision. The skin was infiltrated with 1% lidocaine-epinephrine. The skin was then opened with monopolar cautery and strict attention to hemostasis was paid using bipolar and monopolar cautery. We divided the underlying subcutaneous tissues with monopolar cautery and advanced self-retaining retractors within the wound. We took down the paraspinous musculature insertions off the spinous process and lamina of T6-T11 and extended the muscle resection laterally over the bodies of T7, T8, T9 and T10 going out over the costal margins bilaterally. Having obtained our exposure, we then placed our self-retaining Gelpi retractors within the wound. We verified the location of the T8-T9 interspace using C-arm guidance, and this was marked indelibly. We then took down the spinous processes using a Leksell rongeur and saved this bone for later autograft. We thinned down the lamina using the Leksell rongeur, and then were able to develop a plane at the lower margin of T9, detaching  the ligamentum flavum and then resecting the lamina of T8 and T9. With doing so, we did expose the central thecal sac. We did have intermittent loss of the motor evoked potential in the right lower extremity. Arrest was given to the case and anesthesia was lightened. This did improve somewhat with the exception of the quadriceps. We maintained this new baseline throughout the case with a severely decreased quadriceps motor evoked potential. Having completed our midline exposure, we then removed the T8-T9 facet complex bilaterally, as well as the rib head of T8. This provided us excellent exposure of the lateral margins of the vertebral body, exposing the T8-T9 disc space. We used the Midas Rex with an AM-8 bit to drill down the T9 pedicle, likewise improving and extending our exposure. Having completed our exposure, we then, using loupe magnification with headlight augmentation, incised the T8-T9 disc space sharply. We used a variety of Epstein down-biting curets to gently detach the dura from the PLL, and delivered the disc material into a trough that had been drilled underneath the thecal sac with a Midas Rex with an AM-8 bit. We were able to successfully do this, particularly on the left-hand side. However, on the right-hand side, the disc was tightly adherent to the dura. We did, using microdissection, attempt to detach the T8-T9 disc, the dura was opened. This proved that the disc herniation itself was intradural. We draped and brought the operating microscope within the field. We packed off the lateral recess regions with Cottonoids containing a dry field. We incised the dura sharply with a #15 blade and extended the durotomy using sharp microdissection. We tacked back the dural edges with a series of 4-0 Nurolon sutures. On the right-hand side, we identified 2 dentate ligaments. The dentate ligaments were incised with spring-type microscissors. There was a vascular loop that did come laterally from the dural surface out onto the dorsal aspect of the spinal cord. We did have to work around this in order to preserve this. Using careful microdissection, we were able to gently roll the right lateral aspect of the cord and expose the underlying calcified herniated disc which was intradural. This was sharply dissected off the dura using a #11 blade and delivered into our cavity created in the T8-T9 disc interspace. We were then able to reach in laterally, grab this with a small pituitary, and incise the last dural piece which was attaching it. There was no evidence of attachment onto the spinal cord itself. We then performed a dural patch by taking a small pledget of dura/paradural placement product, and sliding it between the spinal cord and the dural defect. This was tacked up against the dura using a series of 4-0 Nurolon sutures. We then created a sling of dura/paradural placement product and placed this underneath the thecal sac and sutured this in place as well. This did provide somewhat of a watertight seal. Having completed this, we then closed the dura with a running 5-0 Prolene suture. The suture line was watertight. We then attached the Stealth target to the spinous process of T7. We covered the wound and draped the patient appropriately. We brought the O-arm within the field. We did an O-arm scan of the patient's thoracic spine, and registered it within 3-dimensional  space. We then removed the O-arm and brought the C-arm within the field. We verified the accuracy of our Stealth image guidance. Using Stealth image guidance with lateral C-arm fluoroscopy, we cannulated the bodies of T7, T8, T9 and T10, each time probing the pedicle screw path to ensure that there was no breach. We repeated motor evoked potentials with each placement of the
screw. All screws were pretapped. The screws were then placed into the bodies of T7, T8, T9 and T10 bilaterally using the above-listed screws. We repeated our motor evoked potentials. This was unchanged. We distracted the T8-T9 interspace. We then placed a 25 mm x 8 mm Verte-Stack  rescent PEEK withinthe discectomy space. We verified its placement using C-arm. There was no change in motor evoked potentials. It was clear that the dura was well decompressed with no pressure from the Verte-Stack graft. We then compressed across the graft at T8-T9 and tightened the set screws. We then irrigated the wound again with copious amounts of normal saline. We sized and placed 2 x 5.5 mm x 10 cm precut rods. We obtained AP and lateral thoracic spine films. The placement of the screws and the rods was  excellent. We tightened down all the set screws to their endpoints. We placed two 5.5 mm cross-links. We then decorticated the posterolateral elements. We laid down a small BMP pack along the posterolateral elements and used the patient's autograft mixed with pyogenic demineralized bone matrix laterally. We then approximated the muscle with a series of interrupted 0 Vicryl sutures, followed by closely spaced 0 Vicryl to the fascia, followed by interrupted, inverted 2-0 Vicryl to Scarpa's fascia, followed by  nterrupted, inverted 3-0 Vicryl to the subdermal tissues, followed by staples to the skin. At the end of this procedure, all sponge and needle counts were correct. The patient was extubated and transferred to the PACU in stable condition.


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## nlnunn76@att.net (Aug 20, 2012)

*What arthrodesis code to use?*

Can anyone give any thought to whether we should use code 22633 with add on code 22634 or 22612 with add on code 22614 for this operative report?  We are a bit of dilemna with the wording of the operative report b/c it should be reported as bilateral procedure as both left and right side were approached.  

The patient was prepped and draped in the usual sterile fashion in the prone position with care taken to avoid all pressure points. We made a 4cm incision 6cm from midline overlying l4-5 as directed by intraoperative fluoroscopy. Through this incision we placed an 80 mm minimally invasive tube, which was 22 mm in diameter. We docked this on the joint at l4-l5 and carried out a careful reoperative foraminotomy from the transforaminal approach.  We visualized the scar tissue overlying the l4 and l5 nerve roots and freed them totally. Under the operating microscope, we also performed a total facetectomy and osteotomy to further decompress the nerve roots and ensure our access to the disc space from the transforaminal approach.  The evoked potential measurements concerning l5 improved markedly.  We then opened a rectangular window into the disc space, placed the optimesh cannulas through the portal, and obtained ap and lateral fluroscopic imaging.  We proceeded to deploy the dacron mesh filled with allograft and bmp, tensioning the graft appropriately.  We introduced autograft harvested from the decompression through a funnel prior to filling the mesh.  The location of the mesh was midline and midposition on the lateral images as well.  With this accomplished, we started the pedicle screw phase of the procedure placing pedicles screws of 45mm in length and 6.5 mm diameter in the pedicles of l4 and l5 on the left side.  We used the sea-spine system and kept for secured torque after pedicle screw stimulation also suggested safe placement of the screws.  We then prepared the lateral and transverse prostheses of l4 and l5 on the left side for lateral grafting.  This was done with a combination of autograft and surge dbm.  We formed a solid plug and placed against the opened corticles of the transverse prostheses of l4 and l5 and then closed the fascia overlying the lateral compartment.  We then turned our attention to the right side, where we placed a contralateral l4-5 facet screw measuring 30 mm in length across the facet joint guided by fluroscopic imaging in ap and lateral aspects.  Incision was just right of midline and cephalad to the other incision allowing us to achieve the correct angle.  Final imaging was satisfactory.  The evoked potentials remained stable and we closed both incisions using 2.0 vicrly and steri-strips.


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