Joyce Burchett
Networker
Need help with this surgery!! We coded with CPT 63005 & I'm not sure this is correct. Op Report: 75 year old w/spinal stenosis lumbar spine. Has had neurogenic claudication & compression of thecal sac. Midline skin incision & electrocautery was used to dissect down into the inner laminar space @L3-4, L4-5, & L5-S1. I removed the spinous process of L4 & L5, thinned the lamina with Leksell & high-speed bur. I used kerrison punch to resect lamina of L4 & L5 in entirety. At L4-5 he had a lot of facet arthritis contributing to his stenosis, but at L3-4, L5-S1 had stiff epidural fat that was compressing thecal sac. Once this was removed the thecal sac expanded & looked very normal. I placed metallic objects in the epidural space & checked lateral fluoroscopic view. Happy with extent of decompression, I irrigated witha liter of sterile saline, sprinkled ha gram of vancomycin power in his wound & closed fascia, subcutaneous tissue & skin. Any help would be appreciated.