mfournier
Networker
Hello:
Would someone be able to take a peek at this note? Not sure if all these codes are correct. The only path I have is this " Metastatic malignant neoplasm with epithelioid and sarcomatoid features to bone consistent with the patient's known high-grade urothelial carcinoma with sarcomatoid differentiation, see note.
- The specimen was decalcified (2 blocks).
B. Specimen designated "T12 tumor":
- Metastatic malignant neoplasm with epithelioid and sarcomatoid features to bone consistent with the patient's known high-grade urothelial carcinoma with sarcomatoid differentiation, see note.
63277
22610
22112
22842
22614
61783
20930
T11 - T12 laminectomy, partial corpectomy T12 for tumor debulking, hybrid open and minimally invasive T10 - L3 instrumented fusion with screws, rods, and allograft, vertebral cement augmentation, intraoperative neuromonitoring and Brain Lab image guided navigation
OPERATION IN DETAIL: The patient was taken to the operating room, and following confirmation of operative side and site based on the medical record, was intubated under general endotracheal anesthesia. Neurophysiologic monitoring leads for upper and lower extremity motor-evoked and somatosensory-evoked potentials and triggered EMG were placed.The patient was rotated into the prone position on the Jackson table. All pressure points were padded. The skin of the back was prepped and draped in the standard sterile surgical fashion. The midline incision was make with a #10 blade, using landmarks, between approximately T10 and L2, and the electrocautery was used to denude the lamina and spinous processes of the soft tissue and bone and muscle for these levels. The clamp for the navigation reference frame was placed on thea lumbar appearing spinous process and the intraoperative CT scan was performed, and the position of the clamp was confirmed to be the L1 spinous process. The K-wires were then inserted into the T10 and T11 pedicles using Jamshidi needles and image guidance from the intraoperative CT. L2 and L3 pedicle cannulation was performed using the same technique through a separate stab incision, opened with a knife blade and dissected down to the level of the fascia with the fasciotomy performed with a knife blade, and Jamshidi needles were inserted through this onto the transverse process of L2. The sheaths of the Jamshidi needles were removed and the intraoperative CT scan confirmed satisfactory wire placement. The screws at T10, T11, L2 and L3 were placed from the Viper 2 minimally invasive set bilaterally. The triggered EMG was used to stimulate the right sided screws and no potentials past threshold were reported. The connecting rod was contoured into the appropriate position and installed across the screw extensions to span all screws and was secured to the screw heads with set screws on the left only. The laminectomy was performed bilaterally with a power drill from cephalad to caudad aspect of the lamina of T11 and T12 and the lamina removed en bloc. Partial facetectomy T11-T12 and resection of the pedicle was then performed on the right. Tumor in the epidural space ventral to the thecal sac was then visualized. The Penfield and Woodson dissectors were used to develop the plane between the undersurface of the thecal sac and the tumor, and the partial corpectomy of about 30% of the T12 vertebra which had been replaced with tumor performed and the tumor debulked using the pituitary rongeur and the Epstein curet. The Woodson tool was used to confirm no more canal stenosis from tumor on the left. Flo Seal agent was used to achieve hemostasis and copious irrigation was performed. Hemostasis was satisfactory. The rod was contoured and installed across the right sided T10- L3 screws and secured provisionally with the set screws and the left sided rod removed, and the facetectomy of T11 - T12 and the T12 partial corpectomy about an another 25% of the vertebral body which had been replaced by tumor, with tumor debulking, was performed on the left side. The satisfactory debulking of the tumor was assess by confirming with a Woodson tool that the canal stenosis from the epidural tumor extension had been alleviated on both sides. Irrigation and hemostasis were performed on the left side using the same technique as described above for the right side. The intraoperative CT was then repeated to confirm satisfactory screw placement and this was confirmed. The cement vertebral augmentation was then performed down all the left sided screws except for the left T11 screw. The rod was then secured across both the screws heads on the left with the set screws, and the right sided rod removed, the screw heads on the right stimulated with the triggered and EMG with no potentials past threshold reported, and the cement augmentation repeated down the T10, T11, L2 and L3 screws on the right using the same technique as described above for the left sided screws. The rod was installed and secured across the right sided screw heads and the set screws for all screws on both sides were then final tightened to the requisite torque. The screw extensions were all removed. Copious irrigation was performed and hemostasis was satisfactory. The power drill used to decorticate the residual facet surfaces of T10 - T11 and the transverse processes of L2 and L3 down the separate fasciotomies. Vivigen allograft was then packed down the fasciotomies to contact all decorticated bony surfaces to provide a posterolateral arthrodesis. Vancomycin powder was used to coat all the wound bed soft tissue surfaces. The muscle and skin edges were infiltrated with 0.25% bupivacaine in sterile saline. One medium sized Hemovac drain catheter was then into the epidural space in the main midline incision, and another in the epifascial space, and each was brought through an external stab hole adjacent to the main incision line and was secured to the skin using a 2-0 nylon stitch. The wounds were then reclosed in layers with interrupted 0 Vicryl sutures in the fascia, and 2-0 Vicryl sutures in the dermis, and staples on the skin edges externally. The skin edges were dressed with Xeroform, Telfa and Tegaderm. No neurophysiologic monitoring changes were reported by the end of the procedure.
DISPOSITION: The patient was rotated off the operating table, extubated, and returned to the post anesthesia care unit for further care.
Thank you kindly.
MF
Would someone be able to take a peek at this note? Not sure if all these codes are correct. The only path I have is this " Metastatic malignant neoplasm with epithelioid and sarcomatoid features to bone consistent with the patient's known high-grade urothelial carcinoma with sarcomatoid differentiation, see note.
- The specimen was decalcified (2 blocks).
B. Specimen designated "T12 tumor":
- Metastatic malignant neoplasm with epithelioid and sarcomatoid features to bone consistent with the patient's known high-grade urothelial carcinoma with sarcomatoid differentiation, see note.
63277
22610
22112
22842
22614
61783
20930
T11 - T12 laminectomy, partial corpectomy T12 for tumor debulking, hybrid open and minimally invasive T10 - L3 instrumented fusion with screws, rods, and allograft, vertebral cement augmentation, intraoperative neuromonitoring and Brain Lab image guided navigation
OPERATION IN DETAIL: The patient was taken to the operating room, and following confirmation of operative side and site based on the medical record, was intubated under general endotracheal anesthesia. Neurophysiologic monitoring leads for upper and lower extremity motor-evoked and somatosensory-evoked potentials and triggered EMG were placed.The patient was rotated into the prone position on the Jackson table. All pressure points were padded. The skin of the back was prepped and draped in the standard sterile surgical fashion. The midline incision was make with a #10 blade, using landmarks, between approximately T10 and L2, and the electrocautery was used to denude the lamina and spinous processes of the soft tissue and bone and muscle for these levels. The clamp for the navigation reference frame was placed on thea lumbar appearing spinous process and the intraoperative CT scan was performed, and the position of the clamp was confirmed to be the L1 spinous process. The K-wires were then inserted into the T10 and T11 pedicles using Jamshidi needles and image guidance from the intraoperative CT. L2 and L3 pedicle cannulation was performed using the same technique through a separate stab incision, opened with a knife blade and dissected down to the level of the fascia with the fasciotomy performed with a knife blade, and Jamshidi needles were inserted through this onto the transverse process of L2. The sheaths of the Jamshidi needles were removed and the intraoperative CT scan confirmed satisfactory wire placement. The screws at T10, T11, L2 and L3 were placed from the Viper 2 minimally invasive set bilaterally. The triggered EMG was used to stimulate the right sided screws and no potentials past threshold were reported. The connecting rod was contoured into the appropriate position and installed across the screw extensions to span all screws and was secured to the screw heads with set screws on the left only. The laminectomy was performed bilaterally with a power drill from cephalad to caudad aspect of the lamina of T11 and T12 and the lamina removed en bloc. Partial facetectomy T11-T12 and resection of the pedicle was then performed on the right. Tumor in the epidural space ventral to the thecal sac was then visualized. The Penfield and Woodson dissectors were used to develop the plane between the undersurface of the thecal sac and the tumor, and the partial corpectomy of about 30% of the T12 vertebra which had been replaced with tumor performed and the tumor debulked using the pituitary rongeur and the Epstein curet. The Woodson tool was used to confirm no more canal stenosis from tumor on the left. Flo Seal agent was used to achieve hemostasis and copious irrigation was performed. Hemostasis was satisfactory. The rod was contoured and installed across the right sided T10- L3 screws and secured provisionally with the set screws and the left sided rod removed, and the facetectomy of T11 - T12 and the T12 partial corpectomy about an another 25% of the vertebral body which had been replaced by tumor, with tumor debulking, was performed on the left side. The satisfactory debulking of the tumor was assess by confirming with a Woodson tool that the canal stenosis from the epidural tumor extension had been alleviated on both sides. Irrigation and hemostasis were performed on the left side using the same technique as described above for the right side. The intraoperative CT was then repeated to confirm satisfactory screw placement and this was confirmed. The cement vertebral augmentation was then performed down all the left sided screws except for the left T11 screw. The rod was then secured across both the screws heads on the left with the set screws, and the right sided rod removed, the screw heads on the right stimulated with the triggered and EMG with no potentials past threshold reported, and the cement augmentation repeated down the T10, T11, L2 and L3 screws on the right using the same technique as described above for the left sided screws. The rod was installed and secured across the right sided screw heads and the set screws for all screws on both sides were then final tightened to the requisite torque. The screw extensions were all removed. Copious irrigation was performed and hemostasis was satisfactory. The power drill used to decorticate the residual facet surfaces of T10 - T11 and the transverse processes of L2 and L3 down the separate fasciotomies. Vivigen allograft was then packed down the fasciotomies to contact all decorticated bony surfaces to provide a posterolateral arthrodesis. Vancomycin powder was used to coat all the wound bed soft tissue surfaces. The muscle and skin edges were infiltrated with 0.25% bupivacaine in sterile saline. One medium sized Hemovac drain catheter was then into the epidural space in the main midline incision, and another in the epifascial space, and each was brought through an external stab hole adjacent to the main incision line and was secured to the skin using a 2-0 nylon stitch. The wounds were then reclosed in layers with interrupted 0 Vicryl sutures in the fascia, and 2-0 Vicryl sutures in the dermis, and staples on the skin edges externally. The skin edges were dressed with Xeroform, Telfa and Tegaderm. No neurophysiologic monitoring changes were reported by the end of the procedure.
DISPOSITION: The patient was rotated off the operating table, extubated, and returned to the post anesthesia care unit for further care.
Thank you kindly.
MF