I was actually typing it in and thought it might be too long but I think you're right and posting it here would be the best option.
Procedures in detail: 1) Local Skin Anesthesia in a trajecoty aiming for the L4/5 neufofoamen 2) Local Anesthesia at the high spot of the iliac crest on the surgical side 3) L 3/4 Medican Branch Block 4) L 4/5 Median Branch Block 5) L 3/4 Facet block 6) L 4/5 Facet block 7) L 4/5 Provacative Discography with indigocarmin 8) Partial Resection of L5 vertebral body by removal of bone from the superior articular process of L5 9) Partial resection of L5 vertebral body by removal of bone from the inferior articular process of L4 10) Tranforaminal Microdiscectomy at L 4/5 11) Coblation annuloplasty with radiofrequency application.
Narrative description of procedure:
The patient was transported to the operating room, placed prone position on the Wilson frame, routine monitore were applied, and the back was prepped three times with providine/betadine and alcohol, and draped in a standard sterile surgical fashion. The fluorscopy unit was steriily draped and brought into the field for intraoperative imaging and identification of surgical level.
Under biplanar fluoroscopy the entry point, approach andgle and trajectory aiming for the surgical neuroforamen was identified 25 gauge needle was used for local skin anesthesia around the entry point. A 18 gauge spinal needle was passed into the surgical neuroforamen. A this point, median branch and facet blocks were performed at the surgical level and the level above using a 21 gauge spinal needle. Using dual needle technique, a 20 gauge spinal needle was passed through the 18 gauge spinal needle into the intervertebral disc for provocative discography with transforaminal intradiscal injection of approximately 1-1.5 cc of a mixure of contrast Isovue 300 and indgocarmin. There was internal derrangement of the disc, annular tearing with minimal epidural spread in the target area without intradural or intravascular dilution. The 20 gauge spinal needle was removed and a guide wire was passed through the 18 gauge spinal needle into the intervertebral disc securing the position for the surgical decompression instruments to follow.
Sequentially larger reamers were introduced intot he neuroforamen with constant monitoring of the patient's motor function in the lower extremity on the surgical side. Reamers of varying sizes ranging from 4-9 mm were used. The reaming allwed partial resection of the superior and inferior articular process at the surgical level. A working canula was then introduced.
The spinal endoscope was introduced through the working canula and run with contant low pressure, and low flow NS irrigation and the foraminal anatomy was inspected. The exiting nerve root ws identified and the foraminal decompression was inspected. An endoscopic 3-0 Kerrison rongeur was used to perform an expanded foraminoplasty with further resection of bone from the superior and infreior articular process further facilitating partial recsection of the vertebral body. This allowed access to the lateral recess and hypertrophied ligamentum flavum was identified and resected to gain access to the traversing nerve root. An endochisel was also employed to further expand the foraminoplasty.
These maneuvers allowed adequate visualization of the herniated disc and seceral large fragements were removed fro the intervertebral disc thereby decompression the axilla between the exitin and traversing nerve root and below the dural sack centrally. An Ellman Triggerflex radiofrequency probe was used a) for hemostatisis, and b) for coblation for the intervertebral disc allowinig shrinkage and stabilization of the annular defect. In addition, the procedure allowed further decompression of the central spinal canal by decompressing the central portion of the disc buldge. The trigger flex probe was also used to confirm surgical decompression with intraoperative fluoroscopy.
At the end of the case, the traversing and exiting nerve roots were adequately decompressed and visualized. The surgical site was checked for hemostatisis. Fourty mg of depomedrol were injected epidurally for postoperative reduction fo symptoms. The would was closed with a horizontal matress stich using 4-0 monocryl. Dermabond was applied as a dressing.
There it is. Thank you to anybody willing to review this and help me with the coding. We use a coding company for part of our operative reports and this was sent to them and I am not agreeing with what they came up with.
Thanks again.
