afryberger
Networker
I am not sure about my codes. I have 63045,63048,22595,22600,22842,20930. I am not sure what to use for T1/T2 segment...63016?? I am also not sure about the fusion because its c2-c4. I dont know if 63045 would be right also because I cant figure out where they are talking about the Facetectomy. If anyone could help me out and maybe give a little bit of pointers, that would be awesome.
Patient was brought to the operating room, and anesthetized and fiberoptically
intubated by the anesthesia team. Preoperative antibiotics and steroids were
administered, and the anesthesia team was asked to maintain a mean arterial
pressure of greater than 80 mmHg throughout the procedure. The patient's head was
then secured in a 3-point Mayfield application device, and she was turned prone on
to a Jackson table with the foot board. Her head was kept in a neutral position
and secured to the operating room table. All pressure points were then
appropriately padded, and her arms were secured at her sides and taped inferiorly.
The cervical and upper thoracic region were prepped and draped in usual sterile
fashion. After infiltration with 1% lidocaine with epinephrine, a midline linear
incision was made at the base of the occiput down to the just C5 level.
Dissection through subcutaneous tissue revealed the dorsal cervical fascia. The
fascia was then incised with the Bovie electrocautery along the midline spinous
processes, and dissection was then carried out laterally out through the lateral
aspect of the lateral masses bilaterally from C1-2 junction down to the C5 level.
Of note, the C4-C5 facet joint was left intact. In addition, a subperiosteal
dissection of the C1 posterior arch allowed with the exposure of the lateral
aspect of C2 as well as the rostral aspect of the C2 pedicle. Self-retaining
retractors were placed. Starting pilot holes were then placed at the mid point of
the lateral mass at C2 through C4 after confirming the appropriate levels with
lateral fluoroscopic imaging. Using Midas Rex drill with an M8 drill bit, a
trough was then placed at the junction between the lamina and the medial aspect of
the facet joints bilaterally from C2 down to C4. Using an upbiting curette and
appropriate Kelly clamp, the C2-C4 spinous process and lamina was elevated away
from the thecal sac, with the thecal sac markedly expanding after decompression.
Any sharp bony spicule was then resected with 1-mm Kerrison punch and
foraminotomies were then performed bilaterally. Thrombin-soaked Gelfoam was then
placed along the lateral gutter. Attention was then turned to the instrumentation
portion of the procedure. Using instrument and fluoroscopic guidance as well as
direct visualization, the C2 pedicles were accessed bilaterally, and a 2.5-mm
electric-powered drill was then placed down to a depth of approximately 20 mm. A
ball-tip probe was then placed to confirm no bony violation, as well visualized
the trajectory using lateral fluoroscopic imaging as well as direct visualization
of the rostral, medial, and lateral C2 pedicle. A 3-mm tap was then placed to a
depth of approximately 4-6 mm, and repeat probing revealed no bony violation. As
such, DePuy MOUNTAINEER 26-mm long, 3.5-mm screws were then placed with excellent
purchase. The C3 and C4 levels were then instrumented using 3.5-mm screws, being
14 mm in length, being angled proximally 30-mm laterally, and parallel to the
articular surfaces of the facet joints. Once all 6 screws were placed, lateral
fluoroscopic imaging confirmed excellent position. Two titanium rods were then
cut to appropriate length and secured to each screw head. __________ was employed
to confirm excellent purchase. Copious amounts of antibiotic irrigation was
employed, and antibiotic-soaked lap pad was placed to cover the wound. Using a
combination of lateral fluoroscopic imaging, which was difficult given the
patient's body habitus and the location of the upper thoracic levels, which were
affected, a linear incision was made from the caudal C7 level down to the caudal
T3 level. Although the attempt was made to minimize the length of the linear
incision, unfortunately, only 1-inch of intervening skin between the cervical and
thoracic incisions remained. In order to facilitate retraction, the 2 incisions
were connected, although the intervening fascia was not incised over the C6 and C7
levels. Once again, lateral fluoroscopic imaging confirmed the appropriate
levels. An identical dissection was then performed from the caudal C7 level down
to the rostral T3 level. Using a large Leksell rongeur, the superficial spinous
process and lamina of T1 to T2 level was then resected as well as the rostral from
T3 level. Using the Midas Rex drill with an M8 drill bit, the remaining spinous
process and lamina was drilled down. There was a very large dorsal
osteophyte/calcified ligamentum flavum at the T2-T3 greater than T1-T2 levels.
This was bent down. However, the bone was fused with the outer layer of the dura.
Approximately 1-1/2 hours of additional dissection was employed to separate this
hypertrophic ligament from the dura. Fortunately, this was able to be finally
achieved and with no dural violation. In addition, the rostral aspect of T3 was
similarly resected in order to decompress T2-T3 level. There was marked dorsal
indentation and compression of the thecal sac at both levels. This was entirely
relieved at the conclusion of the procedure. Thrombin-soaked Gelfoam was then
placed in a lateral gutters, after any bony spicules were resected with a 1-mm
Kerrison punch. After several minutes, the Gelfoam was irrigated out. Both
wounds were then copiously irrigated with pulse irrigation of 3 L in volume. The
lateral masses at the C2, C3, and C4 levels were then decorticated and morcellized
autograft was mixed with demineralized bone matrix (DBX), and was placed within
the posterior articular surfaces and overlying the lateral masses. Special
attention was paid to ensure that no bony spicules had migrated over the thecal
sac. The self-retaining retractors were carefully removed and 2 epidural drains
were then placed and tunneled via separate stab incision with 1 drain being placed
at the cervical level and 1 drain being placed at the thoracic level. The dorsal
thoracic and cervical fascia were then reapproximated with #1 Vicryl sutures in an
interrupted fashion, ensuring that the drain was not ensnared by the sutures. The
subcutaneous tissues were then reapproximated with 2-0 Vicryl sutures in an
interrupted fashion. The more superficial subcutaneous tissue was reapproximated
with 3-0 Vicryl sutures in an inverted interrupted fashion and the skin was closed
with staples. A 3-0 nylon sutures were employed to secure the drain at the exit
site. A padded sterile dressing was then applied. The patient was then turned
supine on to the gurney, and the Mayfield head fixation device was removed. The
patient was turned in appropriately neutral position from a cervical spine
standpoints. Once the patient was turned supine of the gurney, a hard cervical
collar was then placed. The patient was awakened and extubated by the anesthesia
team, and was noted to be moving her bilateral upper and lower extremities as
prior to surgery. She was then brought out to the recovery room awake and in
stable condition. There were no complications.
Patient was brought to the operating room, and anesthetized and fiberoptically
intubated by the anesthesia team. Preoperative antibiotics and steroids were
administered, and the anesthesia team was asked to maintain a mean arterial
pressure of greater than 80 mmHg throughout the procedure. The patient's head was
then secured in a 3-point Mayfield application device, and she was turned prone on
to a Jackson table with the foot board. Her head was kept in a neutral position
and secured to the operating room table. All pressure points were then
appropriately padded, and her arms were secured at her sides and taped inferiorly.
The cervical and upper thoracic region were prepped and draped in usual sterile
fashion. After infiltration with 1% lidocaine with epinephrine, a midline linear
incision was made at the base of the occiput down to the just C5 level.
Dissection through subcutaneous tissue revealed the dorsal cervical fascia. The
fascia was then incised with the Bovie electrocautery along the midline spinous
processes, and dissection was then carried out laterally out through the lateral
aspect of the lateral masses bilaterally from C1-2 junction down to the C5 level.
Of note, the C4-C5 facet joint was left intact. In addition, a subperiosteal
dissection of the C1 posterior arch allowed with the exposure of the lateral
aspect of C2 as well as the rostral aspect of the C2 pedicle. Self-retaining
retractors were placed. Starting pilot holes were then placed at the mid point of
the lateral mass at C2 through C4 after confirming the appropriate levels with
lateral fluoroscopic imaging. Using Midas Rex drill with an M8 drill bit, a
trough was then placed at the junction between the lamina and the medial aspect of
the facet joints bilaterally from C2 down to C4. Using an upbiting curette and
appropriate Kelly clamp, the C2-C4 spinous process and lamina was elevated away
from the thecal sac, with the thecal sac markedly expanding after decompression.
Any sharp bony spicule was then resected with 1-mm Kerrison punch and
foraminotomies were then performed bilaterally. Thrombin-soaked Gelfoam was then
placed along the lateral gutter. Attention was then turned to the instrumentation
portion of the procedure. Using instrument and fluoroscopic guidance as well as
direct visualization, the C2 pedicles were accessed bilaterally, and a 2.5-mm
electric-powered drill was then placed down to a depth of approximately 20 mm. A
ball-tip probe was then placed to confirm no bony violation, as well visualized
the trajectory using lateral fluoroscopic imaging as well as direct visualization
of the rostral, medial, and lateral C2 pedicle. A 3-mm tap was then placed to a
depth of approximately 4-6 mm, and repeat probing revealed no bony violation. As
such, DePuy MOUNTAINEER 26-mm long, 3.5-mm screws were then placed with excellent
purchase. The C3 and C4 levels were then instrumented using 3.5-mm screws, being
14 mm in length, being angled proximally 30-mm laterally, and parallel to the
articular surfaces of the facet joints. Once all 6 screws were placed, lateral
fluoroscopic imaging confirmed excellent position. Two titanium rods were then
cut to appropriate length and secured to each screw head. __________ was employed
to confirm excellent purchase. Copious amounts of antibiotic irrigation was
employed, and antibiotic-soaked lap pad was placed to cover the wound. Using a
combination of lateral fluoroscopic imaging, which was difficult given the
patient's body habitus and the location of the upper thoracic levels, which were
affected, a linear incision was made from the caudal C7 level down to the caudal
T3 level. Although the attempt was made to minimize the length of the linear
incision, unfortunately, only 1-inch of intervening skin between the cervical and
thoracic incisions remained. In order to facilitate retraction, the 2 incisions
were connected, although the intervening fascia was not incised over the C6 and C7
levels. Once again, lateral fluoroscopic imaging confirmed the appropriate
levels. An identical dissection was then performed from the caudal C7 level down
to the rostral T3 level. Using a large Leksell rongeur, the superficial spinous
process and lamina of T1 to T2 level was then resected as well as the rostral from
T3 level. Using the Midas Rex drill with an M8 drill bit, the remaining spinous
process and lamina was drilled down. There was a very large dorsal
osteophyte/calcified ligamentum flavum at the T2-T3 greater than T1-T2 levels.
This was bent down. However, the bone was fused with the outer layer of the dura.
Approximately 1-1/2 hours of additional dissection was employed to separate this
hypertrophic ligament from the dura. Fortunately, this was able to be finally
achieved and with no dural violation. In addition, the rostral aspect of T3 was
similarly resected in order to decompress T2-T3 level. There was marked dorsal
indentation and compression of the thecal sac at both levels. This was entirely
relieved at the conclusion of the procedure. Thrombin-soaked Gelfoam was then
placed in a lateral gutters, after any bony spicules were resected with a 1-mm
Kerrison punch. After several minutes, the Gelfoam was irrigated out. Both
wounds were then copiously irrigated with pulse irrigation of 3 L in volume. The
lateral masses at the C2, C3, and C4 levels were then decorticated and morcellized
autograft was mixed with demineralized bone matrix (DBX), and was placed within
the posterior articular surfaces and overlying the lateral masses. Special
attention was paid to ensure that no bony spicules had migrated over the thecal
sac. The self-retaining retractors were carefully removed and 2 epidural drains
were then placed and tunneled via separate stab incision with 1 drain being placed
at the cervical level and 1 drain being placed at the thoracic level. The dorsal
thoracic and cervical fascia were then reapproximated with #1 Vicryl sutures in an
interrupted fashion, ensuring that the drain was not ensnared by the sutures. The
subcutaneous tissues were then reapproximated with 2-0 Vicryl sutures in an
interrupted fashion. The more superficial subcutaneous tissue was reapproximated
with 3-0 Vicryl sutures in an inverted interrupted fashion and the skin was closed
with staples. A 3-0 nylon sutures were employed to secure the drain at the exit
site. A padded sterile dressing was then applied. The patient was then turned
supine on to the gurney, and the Mayfield head fixation device was removed. The
patient was turned in appropriately neutral position from a cervical spine
standpoints. Once the patient was turned supine of the gurney, a hard cervical
collar was then placed. The patient was awakened and extubated by the anesthesia
team, and was noted to be moving her bilateral upper and lower extremities as
prior to surgery. She was then brought out to the recovery room awake and in
stable condition. There were no complications.