MYAEKEL
Contributor
For the wrist denervation procedure below I billed 64772 x4 units, 1 unit for each procedure below. Insurance paid 2 units & rejected the additional 2 as it’s over MUE. Before I appeal I wanted to verify if 64772 is correct for the 3rd/4th procedures. Thanks in advance!
PROCEDURE PERFORMED
1. Complete wrist denervation through a dorsal approach including neurectomy of the posterior
interosseous nerve.
2. Neurectomy of the anterior interosseus nerve.
3. Neurectomy of the dorsal radial sensory nerve articular branches.
4. Neurectomy of the dorsal ulnar sensory nerve articular branches.
With the patient in appropriate position, prep and drape, we began.
We first marked out our surgical approach. There was approximately a 4 cm incision line
between the radius and the ulna dorsally. The incision was slightly biased toward the ulna about a
fingerbreadth proximal to the ulnar head with the starting point of the incision extending proximally. With
the skin marked, the limb was elevated, exsanguinated, and tourniquet was inflated. With the tourniquet
up, the incision was made as noted above. Blunt dissection was carried down to the dorsal aspect of the
digital extensors and the wrist extensors. This initial retinaculum was opened up giving us wide access
to the EDC compartment in the ulnar-sided wrist extensor. By carefully and gently mobilizing the EDC
tendon in a radial direction and holding them with Ragnell retractors, we could identify the interosseous
membrane. Underneath the tendon and superficial to the interosseous membrane, we identified very
clear of the posterior interosseous nerve. With this in place, we incised immediately adjacent to the
posterior interosseous nerve place to the ulnar side to identify the anterior interosseous nerve. With a
gentle spreading to pronator quadratus, we were able to identify the longitudinal extent of the
interosseous nerve. We noted 2 motor branches coming off the interosseous nerve proximally and we
stayed distal to this. The entirety of the nerve distal to this was then removed in length about 15 mm with
bipolar cautery at both ends. We did not disrupt the adjacent artery to the anterior interosseous nerve.
Once the interosseous nerve was removed, we then dissected out the posterior interosseous nerve,
removed about 3 cm of the PIN again using blunt tenotomy to separate the nerve from the artery. We
then used the bipolar to neuroectomize the nerve proximally and distally. We removed about 2.5 cm of
the posterior interosseous nerve. At this point in time, we allowed the tendons to retract back into their
native location. We then used a combination of scissors and finger dissection to work the plane between
the fascia and the subcutaneous skin. By palpation, I could palpate the distal portion of the ulnar head
and then the ulnar side to the ulnar head and even around volarly. With my finger through this space
combined with tenotomies, we identified several articular branches heading directly into the joint capsule
of the ulnocarpal joint. All these were sharply released. A final sweep of the digit confirmed that we
were clear all the way to the volar side of the ulnar head. A very similar technique was then employed
on the radial side where we dissected the subcutaneous plane between the fascia and the subcu skin so
I could palpate the radial styloid. We identified several articular branches traversing this plane, and
these were treated with bipolar cautery. As a finishing maneuver using a finger, we swept all across the
dorsal radial aspect of the wrist and even around to the volar side distal to the radial styloid. At this point
in time, we irrigated copiously with sterile saline. I did repair the interosseous membrane with 3-0 Vicryl
in figure-of-eight fashion. We repaired the subcutaneous skin with 3-0 Vicryl in the dermis and 4-0 nylon
in skin. Bulky soft dressings were applied. No splint was utilized. The patient was stable throughout
and stable upon arrival to Recovery.
PROCEDURE PERFORMED
1. Complete wrist denervation through a dorsal approach including neurectomy of the posterior
interosseous nerve.
2. Neurectomy of the anterior interosseus nerve.
3. Neurectomy of the dorsal radial sensory nerve articular branches.
4. Neurectomy of the dorsal ulnar sensory nerve articular branches.
With the patient in appropriate position, prep and drape, we began.
We first marked out our surgical approach. There was approximately a 4 cm incision line
between the radius and the ulna dorsally. The incision was slightly biased toward the ulna about a
fingerbreadth proximal to the ulnar head with the starting point of the incision extending proximally. With
the skin marked, the limb was elevated, exsanguinated, and tourniquet was inflated. With the tourniquet
up, the incision was made as noted above. Blunt dissection was carried down to the dorsal aspect of the
digital extensors and the wrist extensors. This initial retinaculum was opened up giving us wide access
to the EDC compartment in the ulnar-sided wrist extensor. By carefully and gently mobilizing the EDC
tendon in a radial direction and holding them with Ragnell retractors, we could identify the interosseous
membrane. Underneath the tendon and superficial to the interosseous membrane, we identified very
clear of the posterior interosseous nerve. With this in place, we incised immediately adjacent to the
posterior interosseous nerve place to the ulnar side to identify the anterior interosseous nerve. With a
gentle spreading to pronator quadratus, we were able to identify the longitudinal extent of the
interosseous nerve. We noted 2 motor branches coming off the interosseous nerve proximally and we
stayed distal to this. The entirety of the nerve distal to this was then removed in length about 15 mm with
bipolar cautery at both ends. We did not disrupt the adjacent artery to the anterior interosseous nerve.
Once the interosseous nerve was removed, we then dissected out the posterior interosseous nerve,
removed about 3 cm of the PIN again using blunt tenotomy to separate the nerve from the artery. We
then used the bipolar to neuroectomize the nerve proximally and distally. We removed about 2.5 cm of
the posterior interosseous nerve. At this point in time, we allowed the tendons to retract back into their
native location. We then used a combination of scissors and finger dissection to work the plane between
the fascia and the subcutaneous skin. By palpation, I could palpate the distal portion of the ulnar head
and then the ulnar side to the ulnar head and even around volarly. With my finger through this space
combined with tenotomies, we identified several articular branches heading directly into the joint capsule
of the ulnocarpal joint. All these were sharply released. A final sweep of the digit confirmed that we
were clear all the way to the volar side of the ulnar head. A very similar technique was then employed
on the radial side where we dissected the subcutaneous plane between the fascia and the subcu skin so
I could palpate the radial styloid. We identified several articular branches traversing this plane, and
these were treated with bipolar cautery. As a finishing maneuver using a finger, we swept all across the
dorsal radial aspect of the wrist and even around to the volar side distal to the radial styloid. At this point
in time, we irrigated copiously with sterile saline. I did repair the interosseous membrane with 3-0 Vicryl
in figure-of-eight fashion. We repaired the subcutaneous skin with 3-0 Vicryl in the dermis and 4-0 nylon
in skin. Bulky soft dressings were applied. No splint was utilized. The patient was stable throughout
and stable upon arrival to Recovery.