Ami Denney
Contributor
Please someone respond with some help! I am at a complete loss on coding the vertebral body biopsy that was done in conjunction with the injection.
PREOPERATIVE DIAGNOSIS:1. Lesions of the thoracic spine T2, T3, T7.
2. Thoracic spondylosis with a thoracic radiculitis.
3. Lumbar degenerative disc disease, lumbar spondylosis.
POSTOPERATIVE DIAGNOSIS: SAME
Procedure
#1)Right T2 Transforaminal Thoracic Epidural Steroid Injection; (#2)Biopsy and cultures of T2 vertebral body; (#3)Biopsy and cultures of T7 vertebral body.
Anesthesia:Local and IV Sedation. IV sedation was given under my directi supervision with continuous monitoring by a registered nurse trained in sedation protocols.
Complications:None
Findings:The patient tolerated the procedure well.
Procedure:
PROCEDURE #1: The patient was placed in a prone position on the fluoroscopy table, back was prepped with Betadine allowed to air dry fully and sterilely draped. A skin wheal was raised above the T2 neuroforamen on the using oblique approach. A 25 gauge 2 ½ Chiba needle with a slightly bent tip was advanced through the skin wheal and under careful fluoroscopic control advanced towards the posterior inferior aspect of T2 neuroforamen. AP and lateral views were checked, care was taken to avoid the nerve root. I then injected 1 cc. Of Omnipaque 240 which demonstrated epidurogram and finally the patient received 2 cc's of .75 % Bupivacaine plus 12 milligrams of Celestone. Patient tolerated the procedure well. Patient was watched for a period of time before being discharged with full discharge instructions.
PROCEDURES #2 and #3: The risks, benefits and indications of the procedure were explained to the patient including the option to do nothing at all. He understood these and wished to proceed. The patient was placed in the prone position on the operating room table. His back was prepped with Chloraprep, allowed to air dry, and sterilely draped as above. Skin wheal was raised using 1% Lidocaine, 1 cc at each location, above the right pedicle of T2 and T7. A stab
wound was made with the #11 blade scalpel through the skin wheals above the pedicles of T2 and T7 on the right side. Using oblique approach, the bone trocars were then advanced through the stab wounds and advanced carefully under fluoroscopic control until they struck the posterior aspect of the pedicles of T2 and T7. Then using a bone mallet and careful fluoroscopic control, the tips of the bone trocars were advanced down into the vertebral bodies of T2 and T7 posteriorly. Once in proper position on AP and lateral views, I then, using the bone biopsy device, obtained a biopsy of the 2nd and 7th vertebral bodies which was placed in formalin and sent off for further studies. After this had been accomplished, material was obtained, four cultures, including aerobic, anaerobic, AFB, and fungal, and these were sent off in the appropriate containers. After this had been accomplished the bone trocars were removed intact. The wounds were closed with steri-strips and the patient was taken to the recovery area in satisfactory condition.
PREOPERATIVE DIAGNOSIS:1. Lesions of the thoracic spine T2, T3, T7.
2. Thoracic spondylosis with a thoracic radiculitis.
3. Lumbar degenerative disc disease, lumbar spondylosis.
POSTOPERATIVE DIAGNOSIS: SAME
Procedure
#1)Right T2 Transforaminal Thoracic Epidural Steroid Injection; (#2)Biopsy and cultures of T2 vertebral body; (#3)Biopsy and cultures of T7 vertebral body. Anesthesia:Local and IV Sedation. IV sedation was given under my directi supervision with continuous monitoring by a registered nurse trained in sedation protocols.
Complications:None
Findings:The patient tolerated the procedure well.
Procedure:
PROCEDURE #1: The patient was placed in a prone position on the fluoroscopy table, back was prepped with Betadine allowed to air dry fully and sterilely draped. A skin wheal was raised above the T2 neuroforamen on the using oblique approach. A 25 gauge 2 ½ Chiba needle with a slightly bent tip was advanced through the skin wheal and under careful fluoroscopic control advanced towards the posterior inferior aspect of T2 neuroforamen. AP and lateral views were checked, care was taken to avoid the nerve root. I then injected 1 cc. Of Omnipaque 240 which demonstrated epidurogram and finally the patient received 2 cc's of .75 % Bupivacaine plus 12 milligrams of Celestone. Patient tolerated the procedure well. Patient was watched for a period of time before being discharged with full discharge instructions.
PROCEDURES #2 and #3: The risks, benefits and indications of the procedure were explained to the patient including the option to do nothing at all. He understood these and wished to proceed. The patient was placed in the prone position on the operating room table. His back was prepped with Chloraprep, allowed to air dry, and sterilely draped as above. Skin wheal was raised using 1% Lidocaine, 1 cc at each location, above the right pedicle of T2 and T7. A stab
wound was made with the #11 blade scalpel through the skin wheals above the pedicles of T2 and T7 on the right side. Using oblique approach, the bone trocars were then advanced through the stab wounds and advanced carefully under fluoroscopic control until they struck the posterior aspect of the pedicles of T2 and T7. Then using a bone mallet and careful fluoroscopic control, the tips of the bone trocars were advanced down into the vertebral bodies of T2 and T7 posteriorly. Once in proper position on AP and lateral views, I then, using the bone biopsy device, obtained a biopsy of the 2nd and 7th vertebral bodies which was placed in formalin and sent off for further studies. After this had been accomplished, material was obtained, four cultures, including aerobic, anaerobic, AFB, and fungal, and these were sent off in the appropriate containers. After this had been accomplished the bone trocars were removed intact. The wounds were closed with steri-strips and the patient was taken to the recovery area in satisfactory condition.