# Neurosurgery - Can someone please help me



## ckirkp1 (Jul 29, 2010)

Can someone please help me on what code to use. Here's the procedure.

1. T11-T12 extrapedicular left-sided biopsy of epidural & foraminal mass with partial resection of the T11 & T12 rib heads, as well as partial resection of    T12 pedicle.
2. Use of intraoperative microscope with extradural microsurgical dissection. 

Thanks for any advice!!!!!


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## RebeccaWoodward* (Jul 30, 2010)

I don't know that that there is enough information to provide a code.  I'm assuming this was done through a posterior approach since you mentioned the resection of the T11/T12 rib *heads*.  Was a biopsy performed? If so, what did pathology report?  Was a laminectomy performed?  If possible, it would be helpful to see the op note.


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## ckirkp1 (Aug 3, 2010)

*Here's the OP Note. Thanks for your help!!!!!*

PREOPERATIVE DIAGNOSES:
      1. T11-T12 epidural and left foraminal mass.
      2. Castleman disease.
      POSTOPERATIVE DIAGNOSES:
      1. T11-T12 epidural and left foraminal mass.
      2. Castleman disease.
      PROCEDURES:
      1. T11-T12 extrapedicular left-sided biopsy of epidural and
          foraminal mass with partial resection of the T11 and T12 rib
          heads, as well as partial resection of T12 pedicle.
      2. Use of intraoperative microscope with extradural microsurgical
          dissection.
      3. Use of intraoperative C-arm x-ray.
      4. Use of Stryker Luxor minimally invasive retractor.

      PROCEDURE IN DETAIL:
      The patient was taken to the operating room, underwent a general
      anesthesia, endotracheal intubation.  Subsequently was positioned
      prone on a Wilson frame in the Jackson table.  We proceeded to
      obtain a localizing x-ray after having placed 2 needles; 1  at the
      L3 level, and 1 at the T12 level in the midline.  Lateral lumbar x-
      rays were then obtained and proceeded to count up until the level,
      which was identified as T11-T12.  At that site we then marked a 2.5-
      cm incision that was about 2 cm lateral to the midline.  After
      prepping and draping the skin in the usual sterile fashion, we
      proceeded to infiltrate the skin with 1% lidocaine.  We then
      proceeded to place a Steinmann pin at the level in the center of our
      marked incision, and we obtained another lateral x-ray and
      identified again that we were at the T11-T12 level.  Once this was
      identified, we then proceeded with opening of the incision with a
      #10 blade, which was carried down through the skin, and subcutaneous
      tissue down to the fascia, which was also incised with a #10 blade.
      We then proceeded with blunt dissection down to level of the laminae
      and rib head at T11-T12.  We then proceeded to place our Stryker
      Luxor retractor tubes, and proceeded to dilate the soft tissues
      around that area up until the retractor was docked on the laminae,
      and the rib head at T11-T12.  A 6 cm retractor was then put in place
      and attached with the light source, and the retractor was attached
      to the attachment to the table.  We then proceeded to obtain another
      lateral lumbar x-ray to verify that we were at the adequate level,
      which was the case.  We then proceeded to dissect the soft tissue
      using the Bovie cautery, and the pituitary rongeur up until we were
      able to identify the bone at the rib head and laminae at T11 and
      T12.  Of note is that we elected to proceed more laterally and to
      proceed with an extrapedicular biopsy as this appeared to be a safer
      access, and we would avoid causing any type of pressure on the
      spinal cord.  We proceeded to resect part of the rib head at T11 and
      at T12.  We identified the pedicle of T12.  A thick inflammatory
      mass that appeared to be adherent to the soft tissue structures was
      identified at T11-12.  We were unable to visualize any neurovascular
      element and we proceeded to take a few bites of the mass using a
      small pituitary rongeur.  Some of these were sent for frozen
      pathology, which did reveal an inflammatory or a low-grade
      lymphoproliferative process.  The pathologist was unable to tell on
      the frozen section whether or not we were dealing with Castleman
      disease or a low grade malignancy.  As such, we then elected to
      proceed and resect further biopsy specimens.  In the process we did
      notice the intercostal nerve at that level that was inadvertently
      injured, and cut as it was scarred down and had significant amount
      of inflammatory tissue around it, and was unable to be
      differentiated from the surrounding structures.  Once an other
      specimen of a few millimeters was then resected in a piecemeal
      fashion, we then proceeded to achieve adequate hemostasis using the
      bipolar cautery as well as FloSeal, followed by profuse irrigation
      with antibiotic impregnated saline solution.  We did use the
      intraoperative microscope during resection of the deeper specimen.
      We also spared the laminae __________proceeding with laminectomy
      again to avoid causing possible damage close to the spinal cord as
      the mass appeared to be significantly vascular, and adherent to
      neighboring soft tissues.  Once adequate hemostasis obtained, we
      then proceeded to remove our tubular retractor after profuse
      irrigation with  impregnated saline solution.  We proceeded to
      closure in the usual fashion using 0-Vicryl interrupted suture for
      the fascia, 3-0 Vicryl interrupted suture for subcutaneous tissue,
      and a 3-0 Monocryl subcuticular suture for the skin.


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## RebeccaWoodward* (Aug 4, 2010)

Leaning towards 63276 and 69990.


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## ckirkp1 (Aug 4, 2010)

Thank you so much for your help. I appreciate your help with this and also the other ones you have helped me with. You're awesome!!!!


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## RebeccaWoodward* (Aug 4, 2010)

I appreciate that.  I'm not always on the money but that's what so great about this forum...we can "talk it out".  I've learned alot from this forum, too!


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