MSOATES
New
There is some discussion and disagreement on how the following surgery should be coded. Any Spine coding experts out there that can offer the correct coding of this surgery will be appreciated:
PRINCIPAL PROCEDURE: Removal of previous L5/S1 hardware and L4-L5 Date of surgery 2/2015
Laminectomies, L4-5 TLIF, L3-S1 Posterior Spinal Fusion
DESCRIPTION OF THE PROCEDURE: The patient was brought into the operating room and was given IV prophylactic antibiotics. The patient was sedated and intubated without difficulty by the anesthesia service and appropriate lines placed. His eyes were taped shut after ointment was applied to prevent corneal abrasion. A Foley catheter was inserted. The electrophysiology monitoring team inserted needles in their proper locations. The patient was turned prone on a
Jackson frame. All pressure points were carefully padded. A bear hugger was applied to upper body and SCDs placed on legs. The patient was prepped and draped in standard sterile fashion. Landmarks were used to identify the L4-S1 spinous processes. Local anesthesia was infiltrated in the midline along the marked incision.
The skin was subsequently opened sharply using a #10 scalpel blade. Dissection was carried down superiorly and inferiorly in the midline to expose the supraspinous ligament and lamina. The musculature was elevated subperiosteally to expose the facets bilaterally with Bovie cautery and Cobb elevator. Hemostasis was achieved and self-retaining retractors were then inserted. Dissection was carried out far lateral to expose the transverse process at the L3 to S1 levels. Fluoroscopy were obtained outlining the L3-S1 levels.
The old fusion system was identified from L5-S1 and was removed. It was noted the the bilateral S1 screws were known to be broken. Bilaterally at L5 the same trajectory was used and 7x5x55mm screws were placed. At S1 bilaterally a new trajectory with pedicle finder was made superiorly above the known broken screw left in the S1 body. A feeler was used showed no breaches. A tap was used followed by placement of bilateral 7.5x45mm.
Using anatomical landmarks, we first started by placing pedicle screws on the right side. Entry point was defined on right L3 pedicle followed by pilot hole being drilled. This was cannulated with pedicle finder and probed to ensure no breeches. The hole was tapped and then a 6.5mm x 45mm screw was placed. The screw was stimulated and neuro-monitoring confirmed no stimulation of nerve root below significant threshold. This method was continued on the right L4 with a 6.5 mm x 45 mm screw. Next, the left sided screws were placed in a similar fashion with 6.5x45mm screws placed. All screws were stimulated and found to have no significant nerve irritation.
Subsequently, rongeurs and a 3 and 4 Kerrison were used to remove the L4 and L5 lamina. The ligamentum flavum was easily removed. Thorough dissection was carried to the bilateral L4-5 facet to appropriately decompress the L4 exiting nerve root. The L5 nerve root was also decompressed.
A 90mm rod was placed on the right side and was distracted. On the left side, the inferior articulating process of L4, the L4 Pars and the superior portion of the L5 facet were removed with an oteotome. The dura was exposed medially and the disc space was seen. This was entered using a 15 blade and various instruments were used to remove the disc material. The end plates of the disc space were abraded with rasps. A trial was used to select a size 10 graft. Autologous bone graft was placed into disc space followed by a 12x30mm Medtronic graft that was malleted into place. The right rod was then compressed and screws tightened. We then placed rod into the polyaxial screws on the left using a 80mm rod. The rods were subsequently capped. Fluoroscopy was brought into field sterilely and placement of interbody graft and all screws were confirmed. All screws were then torqued appropriately.
The wound was subsequently copiously irrigated with bacitracin irrigation. Hemostasis was obtained with cautery. Bone graft harvested during the procedure was placed out laterally along transverse processes and lateral bone edges for arthrodesis. A Hemovac drain was placed and brought out superiorly. The fascia was subsequently closed using 1-0 PDS sutures. Marcaine was placed in the fascia and 2-0 PDS were used to close the subcutaneous tissue. The skin was closed using a 2-0 nylon and a sterile dressing was applied.
All sponge counts, needle counts and instrument counts were correct at the end of the case x 2. The patient tolerated the procedure well without any immediate complications. After turned supine and extubated by the anesthesia service, he was taken to the PACU in stable condition.
********************************************************
****Prior surgery note(12 years earlier) for reference****
OSTOPERATIVE DIAGNOSIS: Neurogenic claudication, radiculopathy and
L5-S1 spondylolisthesis.
OPERATION: L5-S1 posterior decompression infusion.
DATE OF OPERATION: 02/20/03.
DESCRIPTION OF PROCEDURE: Patient was brought into the operating room,laid in a supine position. Anesthesia obtained, general endotracheal anesthesia without any difficulty. Patient was then flipped into a prone position and his lower back prepped and draped in the usual fashion. A 5 cm linear midline incision was made over the spinous tip processes of L5 and S1 and carried down through subcutaneous tissues. Hemostasis obtained with bipolar cauterization. A monopolar was used to extend the incision down to the paraspinous muscle fascial layer. The fascia was incised over the spinous tip processes followed by a subperiosteal dissection along the spinous tips and laminae of L4 down through S1 on both sides. Lateral L-spine x-ray confirmed the appropriate location.
The dissection was continued laterally using a monopolar until the facets of L5 and S1 were identified, as well as the transverse processes. This was done on both sides. Retractors were placed into the surgical field. After confirmation with a lateral L-spine x-ray, the pedicle screws were then placed. The L5 spinous tip was then removed with a bone rongeur and the laminae were removed using a bone curette bilaterally. The lamina were removed until the facet joints were encountered. A bone rongeur was then used to remove additional facet in order for placement of the pedicle screw. A 4 mm on-spine drill was then used to drill the cortical bone, where the pedicle screw would be placed into S1. Using the obtained L-spine x-ray, the pedicle screws were then placed into S1 at about a 45-degree superior-inferior angle. A spine tech #360 apparatus was placed using pedicle screws that were 6.5 mm x 45 mm and 6.5 mm x 50
mm. After placement of the S1 pedicle screws attention was then directed to the L5 transverse process, where once again the drill was used to decorticate the lateral margin of the facet and pedicle screws were then inserted into the L5 pedicles bilaterally at about a 30-degree superior-inferior angle. After placement of all four pedicle screws, another lateral L-spine x-ray was obtained and confirmed excellent placement of the screws. The laminectomy decompression was then completed using a combination of bone curettes and Kerrison's.
After removal of the bone, there was significant amount of hypertrophic ligament, this was also removed with Kerrison's. A Gant explorer was used to explore each neural foramen, which were adequately decompressed using Kerrison's. After satisfactory decompression a small piece of Surgicel was laid in the lateral recesses bilaterally followed by a thrombin-soaked Gelfoam over the thecal sac. Fusion rods were then secured to the pedicle screws on both sides followed by one transverse fusion rod. After completing the hardware placement the previously obtained bone graft was chipped into small pieces and then placed in the lateral gutters in order to facilitate fusion. Additional bone Bank graft was also used to supplement the allograft. A medium-sized Hemovac drain was placed. The surgical wound was irrigated with copious amounts of bacitracin irrigation and hemostasis obtained with bipolar cauterization. Closure was then done in the usual fashion using multiple #0 Vicryl sutures to approximate paraspinous muscles followed by multiple interrupted #0 Vicryl sutures in the fascial layer. This was followed by a running #0 Vicryl suture in the fascial layer and multiple #2-0 Vicryl
sutures in the deep subcutaneous tissues. Finally, multiple inverted #2-0 Vicryl sutures were used in the superficial subcutaneous tissues followed by staples on the skin. Xeroform dry gauze and OpSite were placed on the surgical wound. Patient was subsequently awakened and extubated in stable condition before going to recovery room.
PRINCIPAL PROCEDURE: Removal of previous L5/S1 hardware and L4-L5 Date of surgery 2/2015
Laminectomies, L4-5 TLIF, L3-S1 Posterior Spinal Fusion
DESCRIPTION OF THE PROCEDURE: The patient was brought into the operating room and was given IV prophylactic antibiotics. The patient was sedated and intubated without difficulty by the anesthesia service and appropriate lines placed. His eyes were taped shut after ointment was applied to prevent corneal abrasion. A Foley catheter was inserted. The electrophysiology monitoring team inserted needles in their proper locations. The patient was turned prone on a
Jackson frame. All pressure points were carefully padded. A bear hugger was applied to upper body and SCDs placed on legs. The patient was prepped and draped in standard sterile fashion. Landmarks were used to identify the L4-S1 spinous processes. Local anesthesia was infiltrated in the midline along the marked incision.
The skin was subsequently opened sharply using a #10 scalpel blade. Dissection was carried down superiorly and inferiorly in the midline to expose the supraspinous ligament and lamina. The musculature was elevated subperiosteally to expose the facets bilaterally with Bovie cautery and Cobb elevator. Hemostasis was achieved and self-retaining retractors were then inserted. Dissection was carried out far lateral to expose the transverse process at the L3 to S1 levels. Fluoroscopy were obtained outlining the L3-S1 levels.
The old fusion system was identified from L5-S1 and was removed. It was noted the the bilateral S1 screws were known to be broken. Bilaterally at L5 the same trajectory was used and 7x5x55mm screws were placed. At S1 bilaterally a new trajectory with pedicle finder was made superiorly above the known broken screw left in the S1 body. A feeler was used showed no breaches. A tap was used followed by placement of bilateral 7.5x45mm.
Using anatomical landmarks, we first started by placing pedicle screws on the right side. Entry point was defined on right L3 pedicle followed by pilot hole being drilled. This was cannulated with pedicle finder and probed to ensure no breeches. The hole was tapped and then a 6.5mm x 45mm screw was placed. The screw was stimulated and neuro-monitoring confirmed no stimulation of nerve root below significant threshold. This method was continued on the right L4 with a 6.5 mm x 45 mm screw. Next, the left sided screws were placed in a similar fashion with 6.5x45mm screws placed. All screws were stimulated and found to have no significant nerve irritation.
Subsequently, rongeurs and a 3 and 4 Kerrison were used to remove the L4 and L5 lamina. The ligamentum flavum was easily removed. Thorough dissection was carried to the bilateral L4-5 facet to appropriately decompress the L4 exiting nerve root. The L5 nerve root was also decompressed.
A 90mm rod was placed on the right side and was distracted. On the left side, the inferior articulating process of L4, the L4 Pars and the superior portion of the L5 facet were removed with an oteotome. The dura was exposed medially and the disc space was seen. This was entered using a 15 blade and various instruments were used to remove the disc material. The end plates of the disc space were abraded with rasps. A trial was used to select a size 10 graft. Autologous bone graft was placed into disc space followed by a 12x30mm Medtronic graft that was malleted into place. The right rod was then compressed and screws tightened. We then placed rod into the polyaxial screws on the left using a 80mm rod. The rods were subsequently capped. Fluoroscopy was brought into field sterilely and placement of interbody graft and all screws were confirmed. All screws were then torqued appropriately.
The wound was subsequently copiously irrigated with bacitracin irrigation. Hemostasis was obtained with cautery. Bone graft harvested during the procedure was placed out laterally along transverse processes and lateral bone edges for arthrodesis. A Hemovac drain was placed and brought out superiorly. The fascia was subsequently closed using 1-0 PDS sutures. Marcaine was placed in the fascia and 2-0 PDS were used to close the subcutaneous tissue. The skin was closed using a 2-0 nylon and a sterile dressing was applied.
All sponge counts, needle counts and instrument counts were correct at the end of the case x 2. The patient tolerated the procedure well without any immediate complications. After turned supine and extubated by the anesthesia service, he was taken to the PACU in stable condition.
********************************************************
****Prior surgery note(12 years earlier) for reference****
OSTOPERATIVE DIAGNOSIS: Neurogenic claudication, radiculopathy and
L5-S1 spondylolisthesis.
OPERATION: L5-S1 posterior decompression infusion.
DATE OF OPERATION: 02/20/03.
DESCRIPTION OF PROCEDURE: Patient was brought into the operating room,laid in a supine position. Anesthesia obtained, general endotracheal anesthesia without any difficulty. Patient was then flipped into a prone position and his lower back prepped and draped in the usual fashion. A 5 cm linear midline incision was made over the spinous tip processes of L5 and S1 and carried down through subcutaneous tissues. Hemostasis obtained with bipolar cauterization. A monopolar was used to extend the incision down to the paraspinous muscle fascial layer. The fascia was incised over the spinous tip processes followed by a subperiosteal dissection along the spinous tips and laminae of L4 down through S1 on both sides. Lateral L-spine x-ray confirmed the appropriate location.
The dissection was continued laterally using a monopolar until the facets of L5 and S1 were identified, as well as the transverse processes. This was done on both sides. Retractors were placed into the surgical field. After confirmation with a lateral L-spine x-ray, the pedicle screws were then placed. The L5 spinous tip was then removed with a bone rongeur and the laminae were removed using a bone curette bilaterally. The lamina were removed until the facet joints were encountered. A bone rongeur was then used to remove additional facet in order for placement of the pedicle screw. A 4 mm on-spine drill was then used to drill the cortical bone, where the pedicle screw would be placed into S1. Using the obtained L-spine x-ray, the pedicle screws were then placed into S1 at about a 45-degree superior-inferior angle. A spine tech #360 apparatus was placed using pedicle screws that were 6.5 mm x 45 mm and 6.5 mm x 50
mm. After placement of the S1 pedicle screws attention was then directed to the L5 transverse process, where once again the drill was used to decorticate the lateral margin of the facet and pedicle screws were then inserted into the L5 pedicles bilaterally at about a 30-degree superior-inferior angle. After placement of all four pedicle screws, another lateral L-spine x-ray was obtained and confirmed excellent placement of the screws. The laminectomy decompression was then completed using a combination of bone curettes and Kerrison's.
After removal of the bone, there was significant amount of hypertrophic ligament, this was also removed with Kerrison's. A Gant explorer was used to explore each neural foramen, which were adequately decompressed using Kerrison's. After satisfactory decompression a small piece of Surgicel was laid in the lateral recesses bilaterally followed by a thrombin-soaked Gelfoam over the thecal sac. Fusion rods were then secured to the pedicle screws on both sides followed by one transverse fusion rod. After completing the hardware placement the previously obtained bone graft was chipped into small pieces and then placed in the lateral gutters in order to facilitate fusion. Additional bone Bank graft was also used to supplement the allograft. A medium-sized Hemovac drain was placed. The surgical wound was irrigated with copious amounts of bacitracin irrigation and hemostasis obtained with bipolar cauterization. Closure was then done in the usual fashion using multiple #0 Vicryl sutures to approximate paraspinous muscles followed by multiple interrupted #0 Vicryl sutures in the fascial layer. This was followed by a running #0 Vicryl suture in the fascial layer and multiple #2-0 Vicryl
sutures in the deep subcutaneous tissues. Finally, multiple inverted #2-0 Vicryl sutures were used in the superficial subcutaneous tissues followed by staples on the skin. Xeroform dry gauze and OpSite were placed on the surgical wound. Patient was subsequently awakened and extubated in stable condition before going to recovery room.