exploration of laminectomy site

Lisa Heikes

Best answers
I'm looking for a code for exploration of previous laminectomy site and search for possible CSF leak. My physician does not do the best op note. But here is goes.

OP note...The previous incision was opened and the paravertabal muscles were incised I entered a sizable cyst. This was filled with xanthochromic fluid. The cyst did not communicate with the subarachnoid space. We had the patient Valsalva several times by Anesthesia and there was no increased leakage or anything. It was my impression that this was a postoperative resolving hematoma. The cyst wall was obliterated. The epidural space was explored from L3 to the sacrum. The nerve roots were nicely intact. There were no neural elements present outside the dural sac as well. Following this Gelfoam was placed over the dura. The muscle was closed with Vicryl, ....