Hello, I was wondering if someone could help me out. I've been coding spinal cases for only about a yr now. But I'm new to corpectomies. Could someone give me a little advice on how to code this case:
PREOPERATIVE DIAGNOSIS:
1. Cervical HNP C5-6.
2. Cervical HNP C6-7.
3. LUE radiculopathy
POSTOPERATIVE DIAGNOSIS:
1. Same as above.
PROCEDURE PERFORMED:
1. Anterior cervical discectomy and fusion C5-6.
2. Anterior cervical discectomy and fusion C6-7.
3. Partial vertebrectomy C5 for the purpose of decompression and fusion.
4. Partial vertebrectomy C6 for purpose of decompression and fusion
5. Use of allograft bone for fusion C5-6, 6-7.
5. Use of anterior instrumentation over 2-3 vertebral segments.
6. Use of neuromonitoring of spinal cord.
DETAILS OF THE PROCEDURE: After seeing the patient in the preoperative holding area and confirming informed consent and operative site, the patient was taken to the operating room and general anesthesia was induced. He was placed supine on the operating table. Pressure points of all extremities were padded in a routine fashion. He was given routine preoperative prophylactic antibiotics and anesthetic and neuromonitoring devices were attached. A bump was placed between the scapula and the neck was prepped and draped in the standard sterile fashion. After a timeout to confirm the operative site, I then made an incision from the left of midline to the medial border of the left sternocleidomastoid with a #15-blade. Bovie cautery was used to dissect down to the platysma which I divided. I then followed the plane between the carotid sheath and esophagus and trachea down to the prevertebral fascia which I again cleared with a Kittner. I then placed a spinal needle in the C4-5 disc space and confirmed my position with lateral fluoroscopy. Following that I cleared the anterior longitudinal ligament at the longus coli muscles bilaterally from C5-7. I then used a self-retaining retractor and placed it and had the anesthesiologist deflate and re-inflate the DT cuff after 5 seconds.
I started at C5-6 with a #15-blade for annulotomy; however, this disc was so collapsed I ultimately used AM8 high speed burr to burr away the entire disc and the inferior portion of C5 vertebral body. I placed Caspar pins and gently distracted the disc space. I then used, once again, the AM8 high speed burr to burr away more of the inferior portion of the C5 vertebral body and medial uncovertebral joints. I identified and elevated the PLL dividing along its entirety up to the neural foramen where foraminotomies were performed. I could then easily see the glistening surface of the dura and passed a medium-sized nerve hook out the neural foramina. I prepared the end plates with rasp and burr and readjusted my retractor and had the anesthesiologist readjust the ET cuff. I then used a #15-blade for annulotomy at C6-7 followed by, once again, the AM8 high speed burr. I again used the burr to burr away the bulk of the disc as well as the inferior portion of C6. I again used the Caspar self-distracting system to gently distract the disc space and again used the AM8 high speed burr to burr away the inferior portion of the C6 vertebral body and medial uncovertebral joints. Again, at this level I identified and elevated the PLL, dividing along its entirety out to the neural foramen where foraminotomies were again performed. I could again see the glistening surface of the dura and easily passed a medium sized nerve hook out the neural foramina without difficulty. I prepared the end plate with curette, rasp, and burr equipment and at C5-6 placed a 7 mm graft and at C6-7 a 7 mm graft. I then placed a plate holding with provisional fixation. PA and lateral fluoroscopy confirmed acceptable position of the plate so I then placed 14 mm screws x2 at C5, c6 and c7.
PREOPERATIVE DIAGNOSIS:
1. Cervical HNP C5-6.
2. Cervical HNP C6-7.
3. LUE radiculopathy
POSTOPERATIVE DIAGNOSIS:
1. Same as above.
PROCEDURE PERFORMED:
1. Anterior cervical discectomy and fusion C5-6.
2. Anterior cervical discectomy and fusion C6-7.
3. Partial vertebrectomy C5 for the purpose of decompression and fusion.
4. Partial vertebrectomy C6 for purpose of decompression and fusion
5. Use of allograft bone for fusion C5-6, 6-7.
5. Use of anterior instrumentation over 2-3 vertebral segments.
6. Use of neuromonitoring of spinal cord.
DETAILS OF THE PROCEDURE: After seeing the patient in the preoperative holding area and confirming informed consent and operative site, the patient was taken to the operating room and general anesthesia was induced. He was placed supine on the operating table. Pressure points of all extremities were padded in a routine fashion. He was given routine preoperative prophylactic antibiotics and anesthetic and neuromonitoring devices were attached. A bump was placed between the scapula and the neck was prepped and draped in the standard sterile fashion. After a timeout to confirm the operative site, I then made an incision from the left of midline to the medial border of the left sternocleidomastoid with a #15-blade. Bovie cautery was used to dissect down to the platysma which I divided. I then followed the plane between the carotid sheath and esophagus and trachea down to the prevertebral fascia which I again cleared with a Kittner. I then placed a spinal needle in the C4-5 disc space and confirmed my position with lateral fluoroscopy. Following that I cleared the anterior longitudinal ligament at the longus coli muscles bilaterally from C5-7. I then used a self-retaining retractor and placed it and had the anesthesiologist deflate and re-inflate the DT cuff after 5 seconds.
I started at C5-6 with a #15-blade for annulotomy; however, this disc was so collapsed I ultimately used AM8 high speed burr to burr away the entire disc and the inferior portion of C5 vertebral body. I placed Caspar pins and gently distracted the disc space. I then used, once again, the AM8 high speed burr to burr away more of the inferior portion of the C5 vertebral body and medial uncovertebral joints. I identified and elevated the PLL dividing along its entirety up to the neural foramen where foraminotomies were performed. I could then easily see the glistening surface of the dura and passed a medium-sized nerve hook out the neural foramina. I prepared the end plates with rasp and burr and readjusted my retractor and had the anesthesiologist readjust the ET cuff. I then used a #15-blade for annulotomy at C6-7 followed by, once again, the AM8 high speed burr. I again used the burr to burr away the bulk of the disc as well as the inferior portion of C6. I again used the Caspar self-distracting system to gently distract the disc space and again used the AM8 high speed burr to burr away the inferior portion of the C6 vertebral body and medial uncovertebral joints. Again, at this level I identified and elevated the PLL, dividing along its entirety out to the neural foramen where foraminotomies were again performed. I could again see the glistening surface of the dura and easily passed a medium sized nerve hook out the neural foramina without difficulty. I prepared the end plate with curette, rasp, and burr equipment and at C5-6 placed a 7 mm graft and at C6-7 a 7 mm graft. I then placed a plate holding with provisional fixation. PA and lateral fluoroscopy confirmed acceptable position of the plate so I then placed 14 mm screws x2 at C5, c6 and c7.