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elizabethjayne

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Hi,

My op report states a disk protrusion on the right, alleviated through decompression, with a 722.10 dx, L-3-4 level.

Patient also had a stenosis decompression at L4-5. My physician precoded this as a 63047 and 63048, but to me it seems like a 63047 with 63030-59. Please help!
 
Post op d/x:

  • Disk protusion, L3-4
    Stenosis, L4-5
Procedure:
Minimally invasive partial microdiskectomy, L3-4, and L4-5 right stenosis decompression

Narrative:
Using a spinal needle and fluoroscopy, I isolated the L3-4 level. A 16mm incision made with a 15 blade down to fascia. I then used a high-speed bur to perform a thorough laminotomy on the right. I then used Kerrisons to enlarge the laminotomy and mobilized and removed the ligamentum flavum in a piece meal fashion....undercut the superior aspect of the RT L4 lamina using an up-biting Kerrison; upcut the superior articular process of L4 with an up-biting Kerrison. I identified the traversing L4 nerve root and mobilized it medially. Disk protrusion was identrified. Annulotomy was made in a cross shaped fashion. using a nerve hook, I removed the disk protrusion. I reached into the disk space and removed several smaller pieces of disk material. The traversing L4 nerve root was well decompressed.

Then L4-5 right stenosis was decompressed. I dilated up and placed a 16mm retractor on the right L4-5 interlaminar space. I used a high-speed bur to perform a thorough laminotomy on the RT. I used Kerrisons to enlarge the laminotomy. I mobilized and removed the ligamentum flavum in a piecemeal fashion. I undercut the superior aspect of the RT L5 lamina using an up-biting Kerrison; upcut the superior articular process of L5 with an up-biting Kerrison. I identified the traversing L4 nerve root and mobilized it medially. Decompressed the bony impingement on the L5 nerve.
 
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