Help! Spine coding


Ventura, California
Best answers
Hi there. I am new to spine/neuro coding. I could really use some help with this OP note. This is a medicare patient.

Indication for Surgery
57yF with anxiety and bipolar disorder who developed progressive intractible back pain from increasing instability from pseudoarthrosis of a revision/extension T7 to L2 done in 16Sept2016 for proximal junctional kyphosis and an osteopenic burst compression fracture at T9/T10. WE had been following her serially in clinic and with plain film and ct scans documenting progressive instability at the base of her T7-L2 construct with significant progressive backout of her left L2 pedicle screw and loosening of her left L1 and T12 pedicle screws. Her rotatory deformity centerd at L2/3 had worsened with progressive kyphosis centered over the L2/3 segment. She also had known osteoporosis/osteopenia. We had discussed options of management at length with Ms. Sanders and her social network including friends from church and her outpatient psychiatry case workers.

She completed extensive perioperative risk assessment. We have discussed perioperative use of forteo or prolia with endocrinology to augment her bony healing and fixation. Goals, risks, and expectations were discussed at length. We planned exploration of her prior T7-L2 fusion construct with revision extension from T6 to L4 with possible extension to T4 to Ileum.

Preoperative Diagnosis
1. Pseudoarthrosis post status T7 to L2 revision-extension fusion Sept2016 for prior PJK from Harrington rod T10 to L1
2. Progressive lumbar kyphotic deformity
3. Spinal Instability
4. Osteoporosis
5. Mechanical Back Pain
6. Anxiety/Bipolar Disorder

Postoperative Diagnosis
1. Pseudoarthrosis post status T7 to L2 revision-extension fusion Sept2016 for prior PJK from Harrington rod T10 to L1
2. Progressive lumbar kyphotic deformity
3. Spinal Instability
4. Osteoporosis
5. Mechanical Back Pain
6. Anxiety/Bipolar Disorder

1. Exploration of T7-T8-T9-T10-T11-T12-L1-L2 segmental fixation and arthrodesis
2. Removal of Left and Right T8 pedicle screws
3. Placement of Depuy Expedium Right T8 pedicle screw 4.32x35mm with lateral connector/adaptor.
4. Removal of Right L2 pedicle screw
5. Removal of T12, L1 and L2 pedicle screws
6. Placement of Depuy Expedium Left T12 and L1 with 2x 5.0x40mm and L2 pedicle screw 5.0x45mm
7. Vertebral bone marrow harvesting L3 and L4
8. Confidence Vertebroplasty augmentation T8, L1, L2, L3, L4
9. Placement of Depuy Expedium bilateral pedicle screws L3 and L4 with 4x 5.0x45mm
10. Bilateral T6/7 hemilaminotomies
11. Placement of bilateral T6 laminar hooks
12. Bilateral Ponte osteotomies L2-L3-L4
13. Segmental fixation T6-T7-T8-T9-T10-T11-T12-L1-L2-L3-L4
14. Auto/allograft arthrodesis T6-T7-T8-T9-T10-T11-T12-L1-L2-L3-L4 with
2 x 10cc Conform bone allograft, 2x10cc DBX mix, 2x10cc Vitoss soaked with harvested vertebral bone marrow, 30cc morsealized cancellous bone
15. Open reduction and internal fixation of unstable pseudoarthrosis.
16. Old scar excised and revised >30cm

was brought to the operating room in a supine position where anesthesia administered a general anesthetic and intubation. She was then lined appropriately for anesthetic and neuro monitoring. A final time out was completed identifying the patient, the procedure with all pre-operative imaging displayed and her allergy status and antibiotic prophylaxis confirmed.

She was then positioned on a Jackson table prone. With all pressure points appropriately padded and baseline SSEP/EMG/MEP captured in all four extremities we proceeded with prepping and draping usual fashion. Her prior thoracic-lumbar midline scar was easily appreciated. A total of 20cc 0.5% marcaine with epinephrine was infused in her prior incision line. We planned toe extend the incision 2cm superiorly and inferiorly and excised/ellipsed the prior 30cmm incision. Prior scar was sent to pathology for permanent section.

Midline incision through the lumbro-sacral fascia and suberiosteal dissections as completed from T7-T8-T9-T10-T11-L1-L2. Fibrous scar/woven bone and hardware were exposed. The incision was extended superiorly to completely expose the T5/T6 facet and T6 lamina and inferiorly to expose the L2/3, L3/4 facets and L3 and L4 lamina. Deep Gelpi retractors were placed to maintain our exposure. We explored the prior fusion site. Titanium dust and gross screw pullout was seen at right L2 pedicle screw as predicted. Pedicle screws at T8,T12 ,L1 and L2 were loose from suspected pseudoarthrosis. Ms. Sanders anatomy is further complicated by small narrow pedicles that are less then the smallest diameter pedicle screw at <4mm and osteopenia bone with confirmed abnormal bony healing.

The prior segmental fixation was removed from T7-T8-T9-T10-T11-T12-L1-L2 by removing the two trans connectors, unlocking the locking caps and removing the rods bilaterally. We new then removed the left and right T8-T12-L1-L2 pedicle screws. At the L2/3/4 area a noted degenerative rotatory kyphotic scoliosis was present. A L2/3 and L3/4 bilateral ponte osteotomy was performed to increase the mobility of this segment for planned reduction and fixation.

Using standard anatomic landmarks in sequence placed a pilot hole in the transverse process -mid facet junction using Midas rex and AP/lateral flour to confirm the position. A pedicle finding gear shift probe was then placed to depth of 30mm and checked under lateral and ap fluoro. Satisfied with he position the probe was advanced to 45mm and a marker placed in the pedicle.

The T8 pedicle was difficult to revise and secure with a pedicle screw. Prior vertebroplasty cement thru the vertebral body complicated placement of pedicle screw. Only a right T8 pedicle screw was placed. Screw diameters were upsized for T12-L1-L2 pedicle screws.

Bone marrow was harvested from the L3-L4 vertebral bodies. CONFIDENCE vertebropasty cement was then applied to T8-L1-L2-L3-L4 to augment the vertebral bodies prior to placement of DePuy Expedium Screws. Bilateral T6/T7 hemilaminotomies were fashioned to place T6 laminar hooks.

The lamina, facets, transverse process, fibrous scar.woven bone was then decorticated from T6-T7-T8-T9-T10-T11-T12-L1-L2-L3-L4. Flo-seal was used to seal bony bleeding edges.

A 4mm Titanium rod was then sized and curved with anatomic 5_6 thoracic kyphosis and 5_6 lumbar lordosis. The rod was first placed and locked in superiorly from T6-T7-T8-T9-T10-T11 and reduced into L1-L2-L3-L4 using reducing towers and downward pressure. The T8 right pedicle screw required use of lateral connector to bring it inline with the connecting rod. The rod was then locked using locking caps.

Moralized allograft collected from the hemilaminotomies and ante osteotomies was mixed with 30cc MTF allograft cancellous ships, 10cc Conform Allograft bone sponge and 2x10cc Stryker Vitoss strips and packed into the postern-lateral-laminar space.

Open reduction and segmental fixation with auto-allograft-arthrodesis was completed with placement of three cross links one thoracic cross link and two lumbar crosslinks at L2 and L4.

The wound was irrigated with copious amounts of bacitracin impregnated saline. 1g vancomycin was used to powder the wound. Two sub-muscular HVAC drains were placed. The wound was then closed inlayers with 0 viceroy to lumbrosacral fascia, 3.0 vicryl to subcutaneous tissue, and 3.0 moncoryl and derma bond glue to skin.

No Complications
SSEP, EMG/MEP signals remained stabile throughout the case with no changes.

Surgical Sweep Complete (Yes/No/Not Applicable)
complete x2

Thanks for your help!

Kelly, CPC