Wondering how others would code this:
POSTOPERATIVE DIAGNOSIS:
1. Herniated disk left L5-S1
2. Degenerative disc disease L4-5, L5-S1
3. Bulging disk L4-5, no herniated disk
PROCEDURES PERFORMED:
1. Left L5-S1 laminectomy and diskectomy.
2. Left L4-5 laminectomy and exploration of disk without diskectomy
The patient was brought to the operating room. She received preoperative antibiotics with Ancef. Sequential compression boots were placed on the patient's legs. General endotracheal anesthesia was induced. The patient was then turned prone onto the Wilson frame. All pressure points were adequately padded and the patient was secured to the operating room table. The back was cleansed with alcohol and prepped and draped in the usual sterile fashion. The incision and muscles were injected with 0.5% marcaine with epinephrine. Lateral fluoroscopy was used to localize the L5-S1 level with a spinal needle placed to the level of the spinous process and incision was planned for exposure of both L4-5 and L5-S1 levels. An incision was then made with a 15-blade knife through the skin and dermis. Using Bovie electrocautery, I dissected through the subcutaneous tissue down to the fascia. Subperiosteal dissection was then used to expose the L4, L5 and S1 lamina on the left side and a Taylor retractor was inserted lateral to the facet. A curette was placed underneath the L4 and L5 lamina and lateral x-ray was obtained confirming this localization. Microscope was then brought in for the purposes of microscopic dissection. I began drilling away the inferior aspect of the lamina of L4. I drilled this away up to the top of the ligamentum flavum and then dissected the ligamentum flavum inferiorly. The same was then done at L5 and the superior aspect of the S1 lamina was drilled down to ligamentum flavum as well. Ligamentum flavum was then punched away, so the L5 and S1 nerve roots were seen descending. The medial overhanging aspect of the facets was drilled away. Bipolar electrocautery was used to coagulate the epidural veins. I then identified the L5-S1 disk, where there was a large subligamentous herniation. A 15-blade knife was used to incise the disk. Pituitary rongeur was used to remove the disk fragments. I then used Epstein curette to further curette away medially. I used the upbiting peapod rongeur to bite away disk medially. I further removed the disk space on the left side with the straight pituitary rongeur. I removed disk until the disk space was cleaned and there were no remaining fragments. I was then able to palpate with the nerve hook and feel that the S1 nerve root was well decompressed. I then used the nerve hook to palpate superiorly and inferiorly and felt good decompression. I also palpated medially and laterally and again felt good decompression with no remaining fragments and no remaining compression of the nerve roots. The wound was irrigated copiously with antibiotic irrigation. Hemostasis was achieved with bone wax on bleeding bone edges and floseal. I then inspected the L4-5 disk where there was no significant herniation and so diskectomy was not performed. Care was taken to punch away the medial overhanging facet and medial L5 foramen to fully decompress the L5 nerve root. The wound was then irrigated again with antibiotic irrigation and hemostasis was achieved with floseal. The wound was then inspected and hemostasis was confirmed.
POSTOPERATIVE DIAGNOSIS:
1. Herniated disk left L5-S1
2. Degenerative disc disease L4-5, L5-S1
3. Bulging disk L4-5, no herniated disk
PROCEDURES PERFORMED:
1. Left L5-S1 laminectomy and diskectomy.
2. Left L4-5 laminectomy and exploration of disk without diskectomy
The patient was brought to the operating room. She received preoperative antibiotics with Ancef. Sequential compression boots were placed on the patient's legs. General endotracheal anesthesia was induced. The patient was then turned prone onto the Wilson frame. All pressure points were adequately padded and the patient was secured to the operating room table. The back was cleansed with alcohol and prepped and draped in the usual sterile fashion. The incision and muscles were injected with 0.5% marcaine with epinephrine. Lateral fluoroscopy was used to localize the L5-S1 level with a spinal needle placed to the level of the spinous process and incision was planned for exposure of both L4-5 and L5-S1 levels. An incision was then made with a 15-blade knife through the skin and dermis. Using Bovie electrocautery, I dissected through the subcutaneous tissue down to the fascia. Subperiosteal dissection was then used to expose the L4, L5 and S1 lamina on the left side and a Taylor retractor was inserted lateral to the facet. A curette was placed underneath the L4 and L5 lamina and lateral x-ray was obtained confirming this localization. Microscope was then brought in for the purposes of microscopic dissection. I began drilling away the inferior aspect of the lamina of L4. I drilled this away up to the top of the ligamentum flavum and then dissected the ligamentum flavum inferiorly. The same was then done at L5 and the superior aspect of the S1 lamina was drilled down to ligamentum flavum as well. Ligamentum flavum was then punched away, so the L5 and S1 nerve roots were seen descending. The medial overhanging aspect of the facets was drilled away. Bipolar electrocautery was used to coagulate the epidural veins. I then identified the L5-S1 disk, where there was a large subligamentous herniation. A 15-blade knife was used to incise the disk. Pituitary rongeur was used to remove the disk fragments. I then used Epstein curette to further curette away medially. I used the upbiting peapod rongeur to bite away disk medially. I further removed the disk space on the left side with the straight pituitary rongeur. I removed disk until the disk space was cleaned and there were no remaining fragments. I was then able to palpate with the nerve hook and feel that the S1 nerve root was well decompressed. I then used the nerve hook to palpate superiorly and inferiorly and felt good decompression. I also palpated medially and laterally and again felt good decompression with no remaining fragments and no remaining compression of the nerve roots. The wound was irrigated copiously with antibiotic irrigation. Hemostasis was achieved with bone wax on bleeding bone edges and floseal. I then inspected the L4-5 disk where there was no significant herniation and so diskectomy was not performed. Care was taken to punch away the medial overhanging facet and medial L5 foramen to fully decompress the L5 nerve root. The wound was then irrigated again with antibiotic irrigation and hemostasis was achieved with floseal. The wound was then inspected and hemostasis was confirmed.