dsibley67
Networker
Please review the operative note and provide your opinion on the code I should use. I feel it should be coded as 63030LT.
POSTOPERATIVE DIAGNOSES: L3-4 stenosis/disc herniation with radiculopathy
PROCEDURES PERFORMED:
1. Partial L3 laminectomy.
2. Left L3-4 microdiscectomy
We then sterile prepped and draped the lumbar spine in normal fashion. I used a spinal needle and C-arm
imaging to center my incision over the L3-4 motion segment. The skin was then anesthetized and sharply
incised. Bovie cautery was used for hemostasis and to perform a subperiosteal dissection onto the spinous
processes and lamina. I then identified the medial border of the L3-4 facet joints. A self-retaining
retractor was then placed. I again used C-arm imaging to verify I was centered over the appropriate
level. I then used a rongeur to remove the interspinous ligaments at L3-4. I felt I needed to perform a
bilateral laminectomy in order to adequately decompress the canal and be able to safely access the disc. I
therefore used a rongeur to remove the lower two-thirds of the spinous process of L3. A bone scalpel
was then used to perform bilateral laminectomy at L3. These sections of bone were mobilized, undercut
with a curette and removed en bloc. This gave me access to the thecal sac in the midline. I then worked
in the lateral recess with a Kerrison rongeur to decompress the lateral recess bilaterally. An operative
microscope was the utilized working on the patient's left hand side. I performed a medial facetectomy at
L3-4. This gave me visualization of very large disc protrusion. The thecal sac was gently retracted. I
used an intraoperative scalpel to perform an annulotomy. This allowed me to mobilize acute disc material
that was herniated ventrally. Once all disc material was removed, I copiously irrigated the disc space and
probed for any further free fragments which I did not encounter. I the used bipolar cautery to cauterize
the annulotomy and to obtain the epidural venous hemostasis. No sign of CSF leak was noted throughout
the case. The wound was copiously irrigated with antibiotic saline solution. I removed the retractor
system. There was no bleeding and I did not utilize the drain. I injected the tissues with
Bupivacaine/Ketorolac for postop pain control. The fascia was closed with interrupted 0 Vicryl suture.
The skin was closed in layers with subcuticular Monocryl for the surface.
POSTOPERATIVE DIAGNOSES: L3-4 stenosis/disc herniation with radiculopathy
PROCEDURES PERFORMED:
1. Partial L3 laminectomy.
2. Left L3-4 microdiscectomy
We then sterile prepped and draped the lumbar spine in normal fashion. I used a spinal needle and C-arm
imaging to center my incision over the L3-4 motion segment. The skin was then anesthetized and sharply
incised. Bovie cautery was used for hemostasis and to perform a subperiosteal dissection onto the spinous
processes and lamina. I then identified the medial border of the L3-4 facet joints. A self-retaining
retractor was then placed. I again used C-arm imaging to verify I was centered over the appropriate
level. I then used a rongeur to remove the interspinous ligaments at L3-4. I felt I needed to perform a
bilateral laminectomy in order to adequately decompress the canal and be able to safely access the disc. I
therefore used a rongeur to remove the lower two-thirds of the spinous process of L3. A bone scalpel
was then used to perform bilateral laminectomy at L3. These sections of bone were mobilized, undercut
with a curette and removed en bloc. This gave me access to the thecal sac in the midline. I then worked
in the lateral recess with a Kerrison rongeur to decompress the lateral recess bilaterally. An operative
microscope was the utilized working on the patient's left hand side. I performed a medial facetectomy at
L3-4. This gave me visualization of very large disc protrusion. The thecal sac was gently retracted. I
used an intraoperative scalpel to perform an annulotomy. This allowed me to mobilize acute disc material
that was herniated ventrally. Once all disc material was removed, I copiously irrigated the disc space and
probed for any further free fragments which I did not encounter. I the used bipolar cautery to cauterize
the annulotomy and to obtain the epidural venous hemostasis. No sign of CSF leak was noted throughout
the case. The wound was copiously irrigated with antibiotic saline solution. I removed the retractor
system. There was no bleeding and I did not utilize the drain. I injected the tissues with
Bupivacaine/Ketorolac for postop pain control. The fascia was closed with interrupted 0 Vicryl suture.
The skin was closed in layers with subcuticular Monocryl for the surface.