Would either of you be able to take a look at my notes and help me as well, I am wondering if I need to query the provider at all on laterality or number of leads, because I do not understand how you know how many leads and when to bill the add on.
Stage I
SURGICAL PROCEDURE:
Stage I bilateral burr hole craniotomies for implantation of bilateral DBS
electrodes into the subthalamic nuclei.
INDICATIONS:
This is a 71-year-old gentleman with severe Parkinson disease with rigidity
and tremor. He was admitted at this time for placement of bilateral DBS
electrodes into the subthalamic nuclei.
OPERATIVE NOTE:
The patient was initially seen in the holding area where under local
anesthesia 5 fiducials were placed into the skull and then he was sent for a
stealth CT scan. After this, the CT scan was merged with his stealth MRI scan
and he was brought to the operating room where he was initially placed under
conscious sedation. The stealth equipments were registered and entry points
for the electrodes were marked on the scalp. The scalp was prepped and then a
C1 drill was used to place entry holes bilaterally. After this, a horseshoe
shaped incision was outlined and infiltrated with lidocaine and Marcaine
bilaterally over the entry sites. The incisions were carried down to skin,
subcutaneous tissue, galea and periosteum. The flap was developed and secured
and covered with Surgicel. The pneumatic perforator was then used to place
bilateral 14 mm burr holes. The remaining bone was removed and then we put
the Stimloc System into place bilaterally. We initially began on the right
and the NexFrame tower was assembled and our trajectory registered and locked
into place and then we initially placed the guide catheter to above our target
depth and then a microrecording electrode was placed initially at 10 mm above
target depth and was eventually lowered to -1.5 mm below target depth.
Microelectrode recordings were performed and then the microrecording electrode
was removed and the DBS lead was placed with the tip at 1.5 mm below target
depth. We then awakened the patient and stimulation was performed and he was
tested and we felt the lead was in good position with good clinical result
from the stimulation with no side effects. After this we then locked the DBS
electrode into place and the tower was disassembled and we repeated the
procedure on the left with placement of the DBS electrode at -1.5 mm below
target depth. After this, an O-arm navigation spin was performed and we felt
that the electrodes were in good position compared to our target points. We
then locked the left catheter into position and the towers were disassembled,
the locking caps were placed and then boots placed over the electrode leads
and a tunnel was made behind the right occipital region where the boots were
placed. We then irrigated and then closed wounds with 3-0 Vicryl and skin
staples. The fiducials were removed and the fiducial incisions were stapled
and Bactroban ointment was placed over all wounds. The patient was then taken
to recovery room in stable condition.
ESTIMATED BLOOD LOSS:
100 mL.
SPONGE AND NEEDLE COUNT:
Correct.
No intraoperative complications occurred. The patient tolerated the procedure
well. There were no specimens removed for pathology, and I was present for
and performed the entire procedure.
STAGE II
PROCEDURE:
Stage II DBS generator implantation and programming.
INDICATIONS:
This is a 71-year-old gentleman with Parkinson disease, who has undergone the
stage I DBS lead implantation. He was admitted today for the stage II DBS
generator implantation.
OPERATIVE NOTE:
The patient was taken to the operative room, placed under general endotracheal
anesthesia. He was in the supine position with the head turned towards the
left. The right occipital, cervical, thoracic regions were sterilely prepped
and draped in standard fashion. I localized his occipital leads and made a 3
cm incision over these and dissected the leads from the subgaleal space. I
then made a 5 cm transverse incision just below the right clavicle and an
adipose tissue pocket was developed for the generator. The passer was used to
pass lead wires from the occipital incision to the chest incision. Once the
extensions were in place, we connected the DBS leads and then connected these
to the generator. We checked impedance and first programming and it was all
within normal limits. We then closed all wounds with interrupted Vicryl
sutures and skin staples. Bactroban ointment, sterile dressings were applied
and the patient was extubated, taken to the recovery room in stable condition.
ESTIMATED BLOOD LOSS:
Minimal.
SPONGE AND NEEDLE COUNT:
Correct.
COMPLICATIONS:
No intraoperative complications occurred.
The patient tolerated the procedure well. There were no specimens removed for
Pathology. I was present for and performed the entire procedure.
