I would appreciate your opinion on the below report. Considering 21700 for the right thoraic outlet decompression with anterior & middle scalenectomy and neurolysis of the brachial plexus, upper, middle, & lower trunks. Should this be 64713? Also considering 64708 x2 for neurolysis of phrenic nerve and long thoracic nerve. Should these be unlisted?
The anterior scalene muscle was then piecemeal removed with right angle and bipolar. Phrenic nerve was neurolysed proximally and distally. It was actually coursing right next to the suprascapular nerve, which was somewhat anomalous. The entire anterior scalene muscle was released exposing the upper trunk C5, C6 and eventually C7. The C8 and T1 nerve roots were very buried down deep into the wound, were very difficult to access. We then went posteriorly and released the middle scalene muscle in a piecemeal fashion. Identified the long thoracic nerve. This was neurolysed proximally and distally away from the middle scalene muscle until the entire muscle was released. There was some scalene intermedius fibers that were present coursing through the plexus as well as another little vascular pedicle. This required a clip ligature and the muscle fibers were then slowly removed away one by one until the entire C8-T1 nerve root was able to be identified. It was very deep and difficult to access, but we were able to get it. Some of the anterior scalene muscle was then traced inferiorly and excised as was the middle scalene muscle. The checkpoint nerve stimulator was used to confirm the branches of the brachial plexus at the C5, C6, C7, C8, and T1. The phrenic nerve, the suprascapular nerve, and the long thoracic nerve were all identified in the field.
The anterior scalene muscle was then piecemeal removed with right angle and bipolar. Phrenic nerve was neurolysed proximally and distally. It was actually coursing right next to the suprascapular nerve, which was somewhat anomalous. The entire anterior scalene muscle was released exposing the upper trunk C5, C6 and eventually C7. The C8 and T1 nerve roots were very buried down deep into the wound, were very difficult to access. We then went posteriorly and released the middle scalene muscle in a piecemeal fashion. Identified the long thoracic nerve. This was neurolysed proximally and distally away from the middle scalene muscle until the entire muscle was released. There was some scalene intermedius fibers that were present coursing through the plexus as well as another little vascular pedicle. This required a clip ligature and the muscle fibers were then slowly removed away one by one until the entire C8-T1 nerve root was able to be identified. It was very deep and difficult to access, but we were able to get it. Some of the anterior scalene muscle was then traced inferiorly and excised as was the middle scalene muscle. The checkpoint nerve stimulator was used to confirm the branches of the brachial plexus at the C5, C6, C7, C8, and T1. The phrenic nerve, the suprascapular nerve, and the long thoracic nerve were all identified in the field.