laraestokes3
New
Ok-so I want to code this with 63688, 11042 and 11045-but not sure if we should do anything with the leads. It reads to me that they are just clipping them off the generator. SO thinking there is no code for this. Any pain experts out there that can point me in the right direction. Here is the op note. thanks!
1. Explant, spinal cord stimulator generator.
2. Explant, partially two spinal cord stimulator lead wires.
3. Debridement, necrotic tissue of the generator pocket.
4. Send cultures.
5. Pack the generator pocket with wet-to-dry Dakin solution.
6. Fluoroscopic guidance to find the lead wires so they could be removed.
7. Partial excision of peripheral nerve stimulator quad lead.
DESCRIPTION OF PROCEDURE:
After the risks, benefits, and alternatives of the above-named procedure were discussed with the patient including bleeding, infection, nonfunction or partial function of the device, tissue, nerve damage, drug reaction discussed with the patient, the patient agrees to proceed. The patient understands that we may have to remove one of her quad leads from her peripheral nerve stimulator Medtronic and close to the infected generator.
The patient was brought into the operating room, assisted into a left decubitus position, axillary roll. Her hips and knees were flexed and we used pillows and gel pads for patient comfort, arms were on arm boards out way from her body. All joints were in neutral position being sure that her head, neck, thoracic, lumbar spine were all in line and well supported. All monitors were placed. O2 supplementation was placed. Bair Hugger was placed. SCDs were placed after the patient was comfortable and all joints were in relaxed neutral position and adequate sedation provided by anesthesia. We had marked where the spinal cord stimulator cord stimulator lead wires come out to the infected generator site. We had also marked for the quad lead were surrounding close to the generator site. The area was prepped and draped including Ioban. We used 1% buffered lidocaine augmented with 0.25% Marcaine plain. We then made a puncture wound overlying the spinal cord stimulator. The lead wires were approximately 3 inches away from the generator and there were no signs of erythema or infection that far away. With blunt dissection electrocautery, we were able to locate the lead wires. We then pulled back on them firmly from the spinal cord stimulator anchors and then cut them with heavy scissors and cleaned portion of the stimulator wires snapped back into the tissue superiorly. We then cut the other portions of the lead wires so there was none in the puncture pocket. That pocket was cleaned without any signs of infection. We flushed with antibiotic solution copiously then briefly flushed with hydrogen peroxide and copiously flushed it with antibiotic solution. We then closed in three layers 2-0 Vicryl for deep, staples for the skin, and we placed a Aquacel dressing over it to sequester it from the infected pump site which have been sequestered with Ioban. We then placed several 4 x 4 gauze over the Aquacel and then placed Ioban over that in an effort to sequester fat incision from the dirty incision. We then made a separate puncture wound for the quad lead which was close to the generator which we were concerned about being infected and found it easily and we pulled on to pull it tight, to cut it so it would snap back it, just broke and came out through that little puncture site. We then copiously irrigated that, briefly flushed with hydrogen peroxide, copiously irrigated it with antibiotic solution.
We then used #15 scalpel to make an incision over the generator pocket where the small eight-inch diameter sized hole had been draining. Blunt dissection and electrocautery, we were able to pull the generator out of the pocket after we cut the silk sutures, we then swabbed the bottom of the pocket with Q-tips and sent them for aerobic, anaerobic, and fungal cultures. When we pulled the generator out, we were able to pull wires out for the spinal cord stimulator through the generator pocket.
We then debrided the pocket of necrotic tissue utilizing scalpel, electrocautery and scraping and then using 4 x 4 gauze to also rub and scrape any remaining necrotic tissue. We then copiously irrigated with antibiotic solution, briefly flushed with hydrogen peroxide and copiously irrigated with antibiotic solution. We packed the wound loosely wet-to-dry with Dakin solution, placed 4 x 4 and Tegaderms over that. We were able to maintain the isolation of the new incision with Aquacel dressing. The patient tolerated the procedure well and was brought to recovery uneventful. We will see her daily to do wet-to-dry dressing changes until we feel comfortable go every other day. We also will give her 1 g of IV vancomycin in the recovery area and then we scheduled her to have q.12.h. of 1 g of vancomycin through her PICC line through the home health service as she already has arranged. We will also do cross every five doses and adjust accordingly. Once we have definitive identification of any bacteria through the cultures, we will change the antibiotics.
Thank you.
1. Explant, spinal cord stimulator generator.
2. Explant, partially two spinal cord stimulator lead wires.
3. Debridement, necrotic tissue of the generator pocket.
4. Send cultures.
5. Pack the generator pocket with wet-to-dry Dakin solution.
6. Fluoroscopic guidance to find the lead wires so they could be removed.
7. Partial excision of peripheral nerve stimulator quad lead.
DESCRIPTION OF PROCEDURE:
After the risks, benefits, and alternatives of the above-named procedure were discussed with the patient including bleeding, infection, nonfunction or partial function of the device, tissue, nerve damage, drug reaction discussed with the patient, the patient agrees to proceed. The patient understands that we may have to remove one of her quad leads from her peripheral nerve stimulator Medtronic and close to the infected generator.
The patient was brought into the operating room, assisted into a left decubitus position, axillary roll. Her hips and knees were flexed and we used pillows and gel pads for patient comfort, arms were on arm boards out way from her body. All joints were in neutral position being sure that her head, neck, thoracic, lumbar spine were all in line and well supported. All monitors were placed. O2 supplementation was placed. Bair Hugger was placed. SCDs were placed after the patient was comfortable and all joints were in relaxed neutral position and adequate sedation provided by anesthesia. We had marked where the spinal cord stimulator cord stimulator lead wires come out to the infected generator site. We had also marked for the quad lead were surrounding close to the generator site. The area was prepped and draped including Ioban. We used 1% buffered lidocaine augmented with 0.25% Marcaine plain. We then made a puncture wound overlying the spinal cord stimulator. The lead wires were approximately 3 inches away from the generator and there were no signs of erythema or infection that far away. With blunt dissection electrocautery, we were able to locate the lead wires. We then pulled back on them firmly from the spinal cord stimulator anchors and then cut them with heavy scissors and cleaned portion of the stimulator wires snapped back into the tissue superiorly. We then cut the other portions of the lead wires so there was none in the puncture pocket. That pocket was cleaned without any signs of infection. We flushed with antibiotic solution copiously then briefly flushed with hydrogen peroxide and copiously flushed it with antibiotic solution. We then closed in three layers 2-0 Vicryl for deep, staples for the skin, and we placed a Aquacel dressing over it to sequester it from the infected pump site which have been sequestered with Ioban. We then placed several 4 x 4 gauze over the Aquacel and then placed Ioban over that in an effort to sequester fat incision from the dirty incision. We then made a separate puncture wound for the quad lead which was close to the generator which we were concerned about being infected and found it easily and we pulled on to pull it tight, to cut it so it would snap back it, just broke and came out through that little puncture site. We then copiously irrigated that, briefly flushed with hydrogen peroxide, copiously irrigated it with antibiotic solution.
We then used #15 scalpel to make an incision over the generator pocket where the small eight-inch diameter sized hole had been draining. Blunt dissection and electrocautery, we were able to pull the generator out of the pocket after we cut the silk sutures, we then swabbed the bottom of the pocket with Q-tips and sent them for aerobic, anaerobic, and fungal cultures. When we pulled the generator out, we were able to pull wires out for the spinal cord stimulator through the generator pocket.
We then debrided the pocket of necrotic tissue utilizing scalpel, electrocautery and scraping and then using 4 x 4 gauze to also rub and scrape any remaining necrotic tissue. We then copiously irrigated with antibiotic solution, briefly flushed with hydrogen peroxide and copiously irrigated with antibiotic solution. We packed the wound loosely wet-to-dry with Dakin solution, placed 4 x 4 and Tegaderms over that. We were able to maintain the isolation of the new incision with Aquacel dressing. The patient tolerated the procedure well and was brought to recovery uneventful. We will see her daily to do wet-to-dry dressing changes until we feel comfortable go every other day. We also will give her 1 g of IV vancomycin in the recovery area and then we scheduled her to have q.12.h. of 1 g of vancomycin through her PICC line through the home health service as she already has arranged. We will also do cross every five doses and adjust accordingly. Once we have definitive identification of any bacteria through the cultures, we will change the antibiotics.
Thank you.