rockylopez
Networker
I am having difficulties coding this surgery as i am new to neurosurgery can anyone please help.
The op report states
pre op diagosis: Atlantoaxial Instability and Rhuematoid pannus
Procedure:
Removal of right C2-T2 posterior instrumentation.
New occipital to T2 right sided instrumentation.
New left occiput to C3 instrumentation.
Occipital to C3 arthodesis.
Morselized allograft.
Intraoperative fluoroscopy.
Neurophysiologic monitoring.
Anesthesia: General
Estimated blood loss (ML) : 500
No specimens in log
Once the patient was under anesthesia, baslelines MEP and SSEP were obtained. The head of fixated in the Mayfield head holder and patient was positioned with all pressure points padded. Prophylactic antibiotic was administered. Posterior neck was clipped. The area was prepped and draped in a sterile fashion. Timeout was performed. The previous posterior cervical scar was incised and incision extended superiorly towards the external occipital protuberance. Posterior cervical hardware was exposed. The occiput was also exposed in subperiosteal fashion as well as the C1 lamina. Bilateral c1 lateral mass screws were placed. On the left side, a lateral connector was used to connect a new rod going rom the occiput to C1 and connecting to the old rod below the c3 lateral mass screw. The right sided rod was removed. A new rod was extended from the occiput to T2 on the right side. Decortication of occipital bone, posterior lamina of the C1 and lateral masses at C2 and C3 was performed. Morselized allograft was placed alloing the decorticated bone. MEP and SSEP remained stable. Copious irrigation was performed. Hemostasis was ensured. Counts were verified to be correct. a sub fascial Hemovac drain was placed and secured with suture. Closure was performed with 0 vicryl in the fascia and 2-0 vicryl in the dermis. Dermobond prineo was placed on the skin. The patient was extubated and transported to PACU in stable condition.
The op report states
pre op diagosis: Atlantoaxial Instability and Rhuematoid pannus
Procedure:
Removal of right C2-T2 posterior instrumentation.
New occipital to T2 right sided instrumentation.
New left occiput to C3 instrumentation.
Occipital to C3 arthodesis.
Morselized allograft.
Intraoperative fluoroscopy.
Neurophysiologic monitoring.
Anesthesia: General
Estimated blood loss (ML) : 500
No specimens in log
Once the patient was under anesthesia, baslelines MEP and SSEP were obtained. The head of fixated in the Mayfield head holder and patient was positioned with all pressure points padded. Prophylactic antibiotic was administered. Posterior neck was clipped. The area was prepped and draped in a sterile fashion. Timeout was performed. The previous posterior cervical scar was incised and incision extended superiorly towards the external occipital protuberance. Posterior cervical hardware was exposed. The occiput was also exposed in subperiosteal fashion as well as the C1 lamina. Bilateral c1 lateral mass screws were placed. On the left side, a lateral connector was used to connect a new rod going rom the occiput to C1 and connecting to the old rod below the c3 lateral mass screw. The right sided rod was removed. A new rod was extended from the occiput to T2 on the right side. Decortication of occipital bone, posterior lamina of the C1 and lateral masses at C2 and C3 was performed. Morselized allograft was placed alloing the decorticated bone. MEP and SSEP remained stable. Copious irrigation was performed. Hemostasis was ensured. Counts were verified to be correct. a sub fascial Hemovac drain was placed and secured with suture. Closure was performed with 0 vicryl in the fascia and 2-0 vicryl in the dermis. Dermobond prineo was placed on the skin. The patient was extubated and transported to PACU in stable condition.