sharon2014
New
I am having trouble finding the perfect code for this case... I was thinking... 63030 and 22114-22. 
HELP!
PREOPERATIVE DIAGNOSES:
L1-2 Disc herniation with cauda equina syndrome
POSTOPERATIVE DIAGNOSES:
Same
PROCEDURES:
1. L1–2 hemilaminectomy
2. Calcific spur removal and microscopic discectomy
3. Use of operating room microscope.
SURGEON:
INDICATIONS: XXXX is a 26 y.o. male who presents with bilateral lower extremity radiculopathy including pain, numbness and weakness worse with positional irritation. This has been refractory to conservative manangement. He has an MRI that shows a disk herniation at L1-2 which is severely impinging the thecal sac. He has bilateral lower extremity symptoms and I urgently admitted him to the hospital for IV steroids. These situations can lead to a full-blown cauda equina loss in hours, that would include bladder bowel dysfunction and sexual dysfunction. I advised him of the nature of his problem. We discussed treatment options including risks and benefits of each. He understood and elected to proceed. I had this conversation through the interpreter.
FINDINGS: Stenosis, calcific spur and herniated disc.
Specimens: None sent
PROCEDURE: After obtaining informed consent with the interpreter present, the patient was brought to the operating room with pneumatic stockings in place. IV antibiotics and IV steroids were administered. He was intubated under general
endotracheal anesthesia with the neck in a neutral position, no hyperextension. He was turned into the radiolucent laminectomy frame with all pressure points well padded. He was prepped and draped in the usual sterile fashion. Pre-incisional x-ray was accomplished for localization using needles. The incision was opened sharply in the midline and extended down to the fascia. The fascia was opened in one layer with monopolar electrocautery. A subperiosteal dissection was undertaken to expose the lamina at left L1-2 . I verified level, once again, with a lateral x-ray.
Once levels were verified, I proceeded to thin the hemilamina above and hemilamina below the appropriate level with a Midas drill. I also drilled the medial facet. I drilled down to the ligamentum, elevated the ligamentum from the underlying thecal sac and removed it with a combination of Kerrisons and curettes, using microdissection technique. I next completed a partial medial facetectomy opening up the lateral recess to expose the underlying disc problem without disturbing the impinged thecal sac. I was confident that there was enough room for the thecal sac, because I used a minimally invasive approach to decompress the entire sac from a unilateral approach. I chose to do this because of his young age and his interest in athletics. I did not want to compromise both medial facets at this transition zone in the lumbar spine. I achieved epidural hemostasis with the use of microbipolar. I used a #15 blade to open the posterior longitudinal ligament. The disc space was quite narrowed and calcific. The epidural mass was also quite calcific. I had to use multiple instruments to remove the calcific spur and the herniated disc. There was some soft disc, but it was mainly calcified endplates with spurs. I explored under the thecal sac with a variety of tools. I used the down-biting curettes and small Kerrisons to accomplish decompression of the thecal sac and nerve roots. This was a very tedious dissection. It doubled my time in the operating room. I relentlessly continued the dissection until I felt the thecal sac was nicely decompressed. I used the down biting curettes ×2, boss Ruggles and the normal down-biting. I also used a micro-Kerrison, thin Kerrison and up-biting Kerrison. I was able to remove a good portion of the calcific spur and soft disc.
I used a small blunt hook to explore under the thecal sac, to verify that there was no further compression. I was satisfied that I do as much as I could do from a posterior approach. I laid Gelfoam pads soaked in thrombin to reconstitute the disc annulus.
The lateral recess and central canal was nicely decompressed. I proceeded to copiously irrigate the incision with saline and achieved hemostasis with bipolar electrocautery and thrombin soaked Gelfoam.
The incision was closed in layers, by myself, with interrupted 0 Vicryl to approximate the muscle and fascia, inverted 2-0 Vicryl to approximate the subcutaneous tissues and staples to approximate the skin edges. Sponge and needle counts were correct prior to closure x2. Sterile dressings were placed. Patient tolerated the procedure well, was taken to the recovery room where he was extubated and found to be at his neurological baseline with no new deficits appreciated.
HELP! PREOPERATIVE DIAGNOSES:
L1-2 Disc herniation with cauda equina syndrome
POSTOPERATIVE DIAGNOSES:
Same
PROCEDURES:
1. L1–2 hemilaminectomy
2. Calcific spur removal and microscopic discectomy
3. Use of operating room microscope.
SURGEON:
INDICATIONS: XXXX is a 26 y.o. male who presents with bilateral lower extremity radiculopathy including pain, numbness and weakness worse with positional irritation. This has been refractory to conservative manangement. He has an MRI that shows a disk herniation at L1-2 which is severely impinging the thecal sac. He has bilateral lower extremity symptoms and I urgently admitted him to the hospital for IV steroids. These situations can lead to a full-blown cauda equina loss in hours, that would include bladder bowel dysfunction and sexual dysfunction. I advised him of the nature of his problem. We discussed treatment options including risks and benefits of each. He understood and elected to proceed. I had this conversation through the interpreter.
FINDINGS: Stenosis, calcific spur and herniated disc.
Specimens: None sent
PROCEDURE: After obtaining informed consent with the interpreter present, the patient was brought to the operating room with pneumatic stockings in place. IV antibiotics and IV steroids were administered. He was intubated under general
endotracheal anesthesia with the neck in a neutral position, no hyperextension. He was turned into the radiolucent laminectomy frame with all pressure points well padded. He was prepped and draped in the usual sterile fashion. Pre-incisional x-ray was accomplished for localization using needles. The incision was opened sharply in the midline and extended down to the fascia. The fascia was opened in one layer with monopolar electrocautery. A subperiosteal dissection was undertaken to expose the lamina at left L1-2 . I verified level, once again, with a lateral x-ray.
Once levels were verified, I proceeded to thin the hemilamina above and hemilamina below the appropriate level with a Midas drill. I also drilled the medial facet. I drilled down to the ligamentum, elevated the ligamentum from the underlying thecal sac and removed it with a combination of Kerrisons and curettes, using microdissection technique. I next completed a partial medial facetectomy opening up the lateral recess to expose the underlying disc problem without disturbing the impinged thecal sac. I was confident that there was enough room for the thecal sac, because I used a minimally invasive approach to decompress the entire sac from a unilateral approach. I chose to do this because of his young age and his interest in athletics. I did not want to compromise both medial facets at this transition zone in the lumbar spine. I achieved epidural hemostasis with the use of microbipolar. I used a #15 blade to open the posterior longitudinal ligament. The disc space was quite narrowed and calcific. The epidural mass was also quite calcific. I had to use multiple instruments to remove the calcific spur and the herniated disc. There was some soft disc, but it was mainly calcified endplates with spurs. I explored under the thecal sac with a variety of tools. I used the down-biting curettes and small Kerrisons to accomplish decompression of the thecal sac and nerve roots. This was a very tedious dissection. It doubled my time in the operating room. I relentlessly continued the dissection until I felt the thecal sac was nicely decompressed. I used the down biting curettes ×2, boss Ruggles and the normal down-biting. I also used a micro-Kerrison, thin Kerrison and up-biting Kerrison. I was able to remove a good portion of the calcific spur and soft disc.
I used a small blunt hook to explore under the thecal sac, to verify that there was no further compression. I was satisfied that I do as much as I could do from a posterior approach. I laid Gelfoam pads soaked in thrombin to reconstitute the disc annulus.
The lateral recess and central canal was nicely decompressed. I proceeded to copiously irrigate the incision with saline and achieved hemostasis with bipolar electrocautery and thrombin soaked Gelfoam.
The incision was closed in layers, by myself, with interrupted 0 Vicryl to approximate the muscle and fascia, inverted 2-0 Vicryl to approximate the subcutaneous tissues and staples to approximate the skin edges. Sponge and needle counts were correct prior to closure x2. Sterile dressings were placed. Patient tolerated the procedure well, was taken to the recovery room where he was extubated and found to be at his neurological baseline with no new deficits appreciated.