Can someone please help me code this spine procedure! I have 64590 & 64585 not sure if this correct. Any help will be greatly appreciated!!!! Thanks!!!!
POSTOPERATIVE DIAGNOSES: 1. Failed peripheral nerve stimulator.
2. Chronic pain syndrome.
PROCEDURES PERFORMED: 1. Removal of peripheral nerve stimulator leads
on the right.
2. Permanent placement of indwelling right
peripheral nerve stimulator.
3. Permanent placement of peripheral nerve
stimulator IPG manufactured by Nalu
a 67-year-old male with a history of previous lumbar spine
fusion surgery. Approximately five weeks ago he had a dual-lead peripheral nerve stimulator placed at an
outside facility. Unfortunately this did not provide him improvement in the symptoms that the original trial
did. Advanced imaging with a CT scan showed the cluneal nerve lead was suprafascial and a likely
source of his failed response to the device. Prior to the procedure we had a long discussion regarding
expectations of removal of the previous leads and implantation of a Nalu internal pulse generator with
revision of leads. He was made aware of the risks prior to surgery. He signed informed consent to
willingly move forward with the surgery
The patient was brought to the operating suite. He was then moved to the prone position on a radiolucent
bed with chest rolls to allow the abdomen to hang free. All prominences were padded to prevent
neuropraxia. He was placed under IV sedation.
We then took an official time-out to verify the correct patient and procedures to be performed. He
received prophylactic antibiotics in the 30 minutes prior to incision. We then sterile prepped and draped
the patient's lumbar spine and right flank in normal fashion. I then took scout images to locate the previous
leads and IPG placed by an outside surgeon. The skin was marked overlying his recent surgical scars on
the right side. Measurements were then taken to locate the proper locations for the Nalu IPG. The
therapy disc was then used to trace with sterile marker for the final location for the IPG. I then used a
scalpel to make small incisions at the locations performed recently by the outside surgeon, in each location
a bipolar cautery was used for hemostasis. I was able to easily identify the leads through the four
different incisions that had been created. Previous sutures were removed. All the leads were identified
and removed through the wounds with no retention of the previous leads. Once these were removed, I
copiously irrigated all the previous wounds with antibiotic saline solution.
One of the incisions was centered directly over the appropriate position to use needles and place the new
leads, therefore I used the 14-gauge introducer needles through the skin and used fluoroscopy for
trajectory. I began with the cluneal nerve lead. This was taken from the PSIS and walked along the
margin of the iliac crest on the right. Once in appropriate position, the internal stylet was removed and a
Nalu 8 contact lead was then advanced. Using x-ray, I verified in AP and lateral imaging that this was
along the iliac crest in a subfascial position. With this in place, a second 14-gauge needle was then used to
advance along the space between the SI joint and the sacral foramen. This medial trajectory was placed
in a more distal fashion than his previous leads had been placed. Again, I used AP and lateral imaging to
advance the lead. The needle was then removed and electrodes were felt to be in appropriate position
along the dorsal sacrum. I then used 0-Vicryl suture to affix both leads in this initial incision. Given the
length of the leads, I then elected to tunnel the leads cephalad into a secondary incision again created
previously in his recent procedure. Both leads were then connected to the electrode interfacing cable and
passed up to the Nalu representative for testing. Impedance check for both leads showed good signal with
no impedance. We then allowed the patient to awake from sedation and testing was performed. The
patient gave a positive response with both leads that he had positive sensation in the appropriate position.
Sedation was then re-instituted for placement of the IPG. A new incision was then made approximately 3
cm in the center where the IPG would be implanted. I pulled the leads into this wound. Both leads were
then cleaned and affixed to the Nalu IPG. I then used the Nalu pocket tunneler as well as a Cobb
elevator to dissect a suprafascial pocket for the IPG. The Nalu therapy disc was then placed overlying
the IPG once again for impedance test which showed good signal. Both leads were secured to the IPG
with a torque screwdriver. The IPG was then inserted into the pocket in appropriate subcutaneous
position. I used sutures in the created wounds again to anchor the leads to the fascia of those was less
likelihood of migration. Final impedance test was conducted. Once the device was implanted and all
signals were good, I rechecked imaging at the level of the pelvis to verify the medial and lateral leads
again were in excellent position.
We again irrigated all wounds with antibiotic saline solution. We then closed the subcutaneous tissue with
interrupted 2-0 Vicryl suture and the skin with staples. A soft sterile dressing was placed. The patient
awoke from sedation without complication. He was returned to the supine position, awoke from
anesthesia and was taken to Recovery in stable condition. He tolerated the procedure well without
apparent complication.
POSTOPERATIVE DIAGNOSES: 1. Failed peripheral nerve stimulator.
2. Chronic pain syndrome.
PROCEDURES PERFORMED: 1. Removal of peripheral nerve stimulator leads
on the right.
2. Permanent placement of indwelling right
peripheral nerve stimulator.
3. Permanent placement of peripheral nerve
stimulator IPG manufactured by Nalu
a 67-year-old male with a history of previous lumbar spine
fusion surgery. Approximately five weeks ago he had a dual-lead peripheral nerve stimulator placed at an
outside facility. Unfortunately this did not provide him improvement in the symptoms that the original trial
did. Advanced imaging with a CT scan showed the cluneal nerve lead was suprafascial and a likely
source of his failed response to the device. Prior to the procedure we had a long discussion regarding
expectations of removal of the previous leads and implantation of a Nalu internal pulse generator with
revision of leads. He was made aware of the risks prior to surgery. He signed informed consent to
willingly move forward with the surgery
The patient was brought to the operating suite. He was then moved to the prone position on a radiolucent
bed with chest rolls to allow the abdomen to hang free. All prominences were padded to prevent
neuropraxia. He was placed under IV sedation.
We then took an official time-out to verify the correct patient and procedures to be performed. He
received prophylactic antibiotics in the 30 minutes prior to incision. We then sterile prepped and draped
the patient's lumbar spine and right flank in normal fashion. I then took scout images to locate the previous
leads and IPG placed by an outside surgeon. The skin was marked overlying his recent surgical scars on
the right side. Measurements were then taken to locate the proper locations for the Nalu IPG. The
therapy disc was then used to trace with sterile marker for the final location for the IPG. I then used a
scalpel to make small incisions at the locations performed recently by the outside surgeon, in each location
a bipolar cautery was used for hemostasis. I was able to easily identify the leads through the four
different incisions that had been created. Previous sutures were removed. All the leads were identified
and removed through the wounds with no retention of the previous leads. Once these were removed, I
copiously irrigated all the previous wounds with antibiotic saline solution.
One of the incisions was centered directly over the appropriate position to use needles and place the new
leads, therefore I used the 14-gauge introducer needles through the skin and used fluoroscopy for
trajectory. I began with the cluneal nerve lead. This was taken from the PSIS and walked along the
margin of the iliac crest on the right. Once in appropriate position, the internal stylet was removed and a
Nalu 8 contact lead was then advanced. Using x-ray, I verified in AP and lateral imaging that this was
along the iliac crest in a subfascial position. With this in place, a second 14-gauge needle was then used to
advance along the space between the SI joint and the sacral foramen. This medial trajectory was placed
in a more distal fashion than his previous leads had been placed. Again, I used AP and lateral imaging to
advance the lead. The needle was then removed and electrodes were felt to be in appropriate position
along the dorsal sacrum. I then used 0-Vicryl suture to affix both leads in this initial incision. Given the
length of the leads, I then elected to tunnel the leads cephalad into a secondary incision again created
previously in his recent procedure. Both leads were then connected to the electrode interfacing cable and
passed up to the Nalu representative for testing. Impedance check for both leads showed good signal with
no impedance. We then allowed the patient to awake from sedation and testing was performed. The
patient gave a positive response with both leads that he had positive sensation in the appropriate position.
Sedation was then re-instituted for placement of the IPG. A new incision was then made approximately 3
cm in the center where the IPG would be implanted. I pulled the leads into this wound. Both leads were
then cleaned and affixed to the Nalu IPG. I then used the Nalu pocket tunneler as well as a Cobb
elevator to dissect a suprafascial pocket for the IPG. The Nalu therapy disc was then placed overlying
the IPG once again for impedance test which showed good signal. Both leads were secured to the IPG
with a torque screwdriver. The IPG was then inserted into the pocket in appropriate subcutaneous
position. I used sutures in the created wounds again to anchor the leads to the fascia of those was less
likelihood of migration. Final impedance test was conducted. Once the device was implanted and all
signals were good, I rechecked imaging at the level of the pelvis to verify the medial and lateral leads
again were in excellent position.
We again irrigated all wounds with antibiotic saline solution. We then closed the subcutaneous tissue with
interrupted 2-0 Vicryl suture and the skin with staples. A soft sterile dressing was placed. The patient
awoke from sedation without complication. He was returned to the supine position, awoke from
anesthesia and was taken to Recovery in stable condition. He tolerated the procedure well without
apparent complication.