cclarson
Guru
Is it safe to say that the tarsal tunnel release (28035) includes fixing the entrapment of both the medial and lateral plantar nerves? Also, would the neurolysis of the calcaneal nerve be included or could it be billed separately using 64704. What does everyone think?
OSTOPERATIVE DIAGNOSES:
1. Tarsal tunnel syndrome, right.
2. Entrapment of the medial plantar nerve.
3. Entrapment of the lateral plantar nerve.
4. Entrapment of the calcaneal nerve.
OPERATIONS PERFORMED:
1. Tarsal tunnel decompression.
2. Neurolysis, medial plantar nerve.
3. Neurolysis, lateral plantar nerve.
4. Neurolysis, calcaneal nerve.
JUSTIFICATION:
The patient has unrelenting pain at his feet. I explained to him that with his multiple spinal surgeries, spinal cord stimulator, and history of chemotherapy, no guarantee as to result can be given. All surgery was done under four-time loupe magnification and with bipolar cautery.
DESCRIPTION OF PROCEDURE:
The patient was brought into the OR in apparently good condition and placed on the OR table in the supine position. Following general anesthesia, the right foot and leg were prepped and draped in the usual sterile manner. The foot was exsanguinated, and a well-padded midthigh tourniquet was inflated. Attention was then directed to the medial aspect of the right ankle overlying the tarsal tunnel where a 4-cm linear incision was made. The incision was deepened via blunt dissection to the level of the flexor retinaculum. The retinaculum was severed. The entire length of the tarsal tunnel and the vessels and nerves were visualized.
Attention was then directed to the plantar aspect of the foot where an incision was made overlying the abductor hallucis connecting to the original incision. The fascia over the abductor was severed, and the abductor hallucis muscle was retracted inferiorly. Utilizing a hemostat, the medial plantar nerve tunnel was identified. It was aiming towards the navicular. The roof of the tunnel was sectioned, and the medial plantar nerve was identified. This completed neurolysis to the medial plantar nerve tunnel. The lateral plantar nerve tunnel was then found. This was going to the plantar aspect of the foot. The roof of this tunnel was opened completing neurolysis of the lateral plantar nerve. Attention was then directed posteriorly towards the back of the heel where a large nerve was running through a tight tunnel. This was the calcaneal nerve, and the roof of this tunnel was opened completing neurolysis of the calcaneal nerve. The operative site was then flushed with copious amounts of sterile saline. Subdermal closure with 4-0 Vicryl, and the skin was closed with 4-0 nylon, and a combination of simple interrupted and running suture technique. Approximately 10 mL of 0.5% Marcaine was infiltrated in the operative site. The area was then dressed utilizing Xeroform, 4x4's, fluffs, Coban, and an Ace wrap. The pneumatic tourniquet was deflated establishing normal capillary refill to all digits. The patient was transferred to the recovery room in an apparently good condition. He will be discharged to home after a brief stay in Recovery and has an appointment to see me early next week.
Thank you!
OSTOPERATIVE DIAGNOSES:
1. Tarsal tunnel syndrome, right.
2. Entrapment of the medial plantar nerve.
3. Entrapment of the lateral plantar nerve.
4. Entrapment of the calcaneal nerve.
OPERATIONS PERFORMED:
1. Tarsal tunnel decompression.
2. Neurolysis, medial plantar nerve.
3. Neurolysis, lateral plantar nerve.
4. Neurolysis, calcaneal nerve.
JUSTIFICATION:
The patient has unrelenting pain at his feet. I explained to him that with his multiple spinal surgeries, spinal cord stimulator, and history of chemotherapy, no guarantee as to result can be given. All surgery was done under four-time loupe magnification and with bipolar cautery.
DESCRIPTION OF PROCEDURE:
The patient was brought into the OR in apparently good condition and placed on the OR table in the supine position. Following general anesthesia, the right foot and leg were prepped and draped in the usual sterile manner. The foot was exsanguinated, and a well-padded midthigh tourniquet was inflated. Attention was then directed to the medial aspect of the right ankle overlying the tarsal tunnel where a 4-cm linear incision was made. The incision was deepened via blunt dissection to the level of the flexor retinaculum. The retinaculum was severed. The entire length of the tarsal tunnel and the vessels and nerves were visualized.
Attention was then directed to the plantar aspect of the foot where an incision was made overlying the abductor hallucis connecting to the original incision. The fascia over the abductor was severed, and the abductor hallucis muscle was retracted inferiorly. Utilizing a hemostat, the medial plantar nerve tunnel was identified. It was aiming towards the navicular. The roof of the tunnel was sectioned, and the medial plantar nerve was identified. This completed neurolysis to the medial plantar nerve tunnel. The lateral plantar nerve tunnel was then found. This was going to the plantar aspect of the foot. The roof of this tunnel was opened completing neurolysis of the lateral plantar nerve. Attention was then directed posteriorly towards the back of the heel where a large nerve was running through a tight tunnel. This was the calcaneal nerve, and the roof of this tunnel was opened completing neurolysis of the calcaneal nerve. The operative site was then flushed with copious amounts of sterile saline. Subdermal closure with 4-0 Vicryl, and the skin was closed with 4-0 nylon, and a combination of simple interrupted and running suture technique. Approximately 10 mL of 0.5% Marcaine was infiltrated in the operative site. The area was then dressed utilizing Xeroform, 4x4's, fluffs, Coban, and an Ace wrap. The pneumatic tourniquet was deflated establishing normal capillary refill to all digits. The patient was transferred to the recovery room in an apparently good condition. He will be discharged to home after a brief stay in Recovery and has an appointment to see me early next week.
Thank you!
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