ammontagano
Guru
Any input would be appreciated in regards to this op note, my question is--can you bill out for the excision of the cyst or just the laminectomies?
The spinous processes and lamina were identified. No laminar defects from previous surgery. There was stable fusion material from the previous surgery. The L2-L3 appeared to be arthrodesed, L3-L4 had motion, and L4-L5 was solidly arthrodesed. I gradually take doen the scar tissue, the perineural scar tissue, some bone tissue, calcified scar tissue and calcified ligamentum flavum. Multiple tissues were present and adherent to the dura. Lysis of adhesions was performed by removing calcified scar tissue around the epidural space, removed from the dura. This found to be only mild central canal stenosis with moderate to moderately severe foraminal stenosois on the right side and mild to moderate on the left side. On the right side at L3-L4 there was found to be a moderate sized synovial cyst compressing not only the thecal sac but the exiting L4 nerve root.
The synovial cyst was excised appros. 2-3 ml of fluid was removed from the cyst upon excision. Foraminotomies were performed by aggressively going into the foraminal exit zone undermining the remaining facet joint and pars interarticularis along each of the nerve root down to its corresponding foraminal exit zone in order to ensure complete decompression of the nerve root. This was done at all 3 levels L2 through L5.
The epidural space was further explored. I did not see any evidence of disk herniation or free fragment disk herniation. Bone taken from the lamina and facet joints was debrided of any soft tissue and morselized and later used for bone graft material.
**Doctor also performed a posterolateral fusion at L3-L5
The spinous processes and lamina were identified. No laminar defects from previous surgery. There was stable fusion material from the previous surgery. The L2-L3 appeared to be arthrodesed, L3-L4 had motion, and L4-L5 was solidly arthrodesed. I gradually take doen the scar tissue, the perineural scar tissue, some bone tissue, calcified scar tissue and calcified ligamentum flavum. Multiple tissues were present and adherent to the dura. Lysis of adhesions was performed by removing calcified scar tissue around the epidural space, removed from the dura. This found to be only mild central canal stenosis with moderate to moderately severe foraminal stenosois on the right side and mild to moderate on the left side. On the right side at L3-L4 there was found to be a moderate sized synovial cyst compressing not only the thecal sac but the exiting L4 nerve root.
The synovial cyst was excised appros. 2-3 ml of fluid was removed from the cyst upon excision. Foraminotomies were performed by aggressively going into the foraminal exit zone undermining the remaining facet joint and pars interarticularis along each of the nerve root down to its corresponding foraminal exit zone in order to ensure complete decompression of the nerve root. This was done at all 3 levels L2 through L5.
The epidural space was further explored. I did not see any evidence of disk herniation or free fragment disk herniation. Bone taken from the lamina and facet joints was debrided of any soft tissue and morselized and later used for bone graft material.
**Doctor also performed a posterolateral fusion at L3-L5
