# What do you see? (Spine)



## RebeccaWoodward* (Jul 10, 2009)

I'm a little torn on this one.  The fusion codes/instumentation aren't the issue.  I'm looking at the diskectomy that was performed but I also see a pars defect.  63012? 63030? I'm leaning a little towards 63012...what do you think?

PREOPERATIVE DIAGNOSES: L3-4 grade I spondylolisthesis with bilateral pars defects and right radiculopathy. 

POSTOPERATIVE DIAGNOSES: L3-4 grade I spondylolisthesis with bilateral pars defects and right radiculopathy. 

PROCEDURE: Right L3-4 translumbar interbody fusion with pedicle screw fixation utilizing Zimmer Optima Pedicle Screw System, bilateral  posterolateral fusion.   

SPECIAL PROCEDURES:  Operative microscope for facetectomy and neural decompression as well as diskectomy, fluoroscopy for greater than 60 minutes for placement of interbody implant and all pedicle screws.  

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room, intubated in his own bed and induced under general anesthesia.  A Foley catheter was placed, as were Thromboguards.  He was then turned into a prone position on the spine table and was positioned according to protocol.  His low back was prepped and draped in the usual fashion.  Fluoroscopy was utilized to mark paramedian incisions, approximately 3 cm off the midline, from the L3 to L4 pedicles.  The incision was first made on the right-hand side and was carried down to the L3 and L4 transverse processes.  The intervening facet joint of L3-4 was dissected free of tissue.  I did the right side, and Dr ** obtained similar exposure to the L3 and L4 transverse processes on the left-hand side.  The left hand facet was not uncovered, as we were going to do the facetectomy from the right.  

Under the operative microscope, a right L3-4 facetectomy was performed.  A pars defect was located and removed as expected.  The grade I spondylolisthesis was identified visually as well as on x-ray.  There was marked compression of the L3 greater than L4 nerve root from a combination of extensive reactive tissue around the pars as well as the spondylolisthesis itself.  Interestingly, after we performed the diskectomy, the spondylolisthesis almost nearly completely reduced itself.  The annulus was identified after complete neural decompression had been carried out, and a complete diskectomy performed, utilizing instrumentation both under the microscope as well as fluoroscopically to decorticate the endplates.  The disk space was distracted with a 10 mm paddle, which was then very tight within the disk space.  Again, the spondylolisthesis already had reduced itself considerably.  Once the disk space was completely prepared for the fusion, autograft was packed anteriorly in the left lateral region, and this was supplemented with BMP.  A 10 mm x 26 mm long PEEK implant was filled with BMP and under fluoroscopic guidance was placed from a right to left direction in the L3-4 disk space.  This was countersunk against the posterior vertebral bodies of both L3 and L4 and crossed the midline nicely on the AP view.  Further BMP and autograft was used to pack posteriorly and laterally to the implant once it was in place, taking care that nothing extruded from the disk space itself.  Hemostasis was achieved in the epidural space.  Valsalva was performed and was negative for CSF leak.  The nerve roots were covered with a layer of Surgicel, and then a layer of a Gelfoam was placed over the interbody site. 

Fluoroscopy was adjusted at this point to allow for pedicle screw placement.  Using frequent and sometimes continuous lateral and frequent AP views, bilateral pedicle screws were placed at L3 and L4.  The Zimmer Optima System was used, and 7 mm in diameter screws were placed, 60 mm long at L3, 55 mm long on the left at L4, and 45 mm long on the right at L4 where the facetectomy had been performed.  All screws showed excellent positioning on fluoroscopic imaging.  Then, 50 mm rods were then placed and secured inferiorly.  I attempted to utilize the spondylolisthesis reduction system to reduce the spondylolisthesis even further, although by now it was just about 2 mm.  It was not possible to reduce it any further; therefore, the set screws were placed superiorly.  Both sides were compressed as the setscrews were placed and tightened down. The transverse processes of L3 and L4 had previously been decorticated after having been extensively exposed.  A combination of residual autograft, cancellous bone chips, and residual BMP were then used to span the transverse processes bilaterally at L3-4 for a posterolateral fusion...


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## martnel (Jul 13, 2009)

I haven't had one of those to code yet, but I am thinking 63012 too?


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## RebeccaWoodward* (Jul 13, 2009)

The surgeon originally submitted the charges without a "60000" code.  When I started reading the op note, It appeared to me that this was missing.  I know that 22630 includes a discectomy to prepare the interspace but this also clearly states "*other than for decompression*".  The op note clearly indicates that a decompression was done but 63012 seems to be a better fit since there was a pars defect and the patient does have spondylolisthesis. I'm going to speak with the surgeon for the seal of approval.  Thanks for responding!!


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