lovetocode
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I know this operative report is long, but I have been studying it for hours. I need another coder's opinion. On the anesthesia record, it is noted that 2 attempts were made at a double lumen tube with the third attempt successful. An a-line (36620) was also placed by anes. as well as ultrasound guided CVP placement (76937-26). What anesthesia code would you use for the following op report? I know I could use 00670 for spinal instrumentation, but could I use 00626 because of the DLT? Does the op report support a transthoracic approach? Thank you in advance to anyone who tackles this case.
POSTOPERATIVE DIAGNOSIS:
1. Metastatic cancer T12 and L1.
2. Pathologic fracture L1.
3. Severe spinal cord compression L1.
4. Severe back and right thigh pain.
OPERATION PERFORMED:
1. Anterior T12 and L1 corpectomies.
2. Anterior decompression spinal cord T12-L1.
3. Anterior reconstruction with cage and anterior plate fixation
at T11 to L2.
4. Anterior fusion at the T11 to L2.
5. Local bone graft harvest through T10 rib.
6. Insertion of demineralized bone matrix allograft.
ANESTHESIA:
General.
COMPLICATIONS:
None.
DESCRIPTION OF OPERATION:
The patient was taken to the operating room and a general
anesthetic was obtained. She was placed in a right lateral
decubitus position. The beanbag positioner was used to maintain
the lateral position. An axillary roll was placed under the down
axilla. The knees were supported with pillows to avoid peroneal
nerve injury and the hips and knees were gently flexed. The
extremities were secured to the table. The body was flexed over
the table with the break in the table being approximately at the
mid flank level to bend the spine somewhat to the right. The
lateral chest was then prepped and draped in the usual sterile
fashion as was the abdomen and this was done after examining the
operative level with the C-arm and confirming the incision site.
The prep and drape was completed per usual protocol and after a
time-out was performed and antibiotics were confirmed
administered, an incision was created in an oblique manner over
the left lower thoracic area. The skin and subcutaneous tissues
were divided. The rib was identified and exposed
subperiosteally. The rib was stripped of soft tissues and then
sectioned at its proximal end with a rib cutter and distally it
was removed from its soft tissue attachment. It appeared to be a
floating rib but it was the T10 rib it turned out.
This appeared to allow visualization of the pleura. With
inspection, it appeared that the best approach would be through
the chest and therefore the pleural was divided. The diaphragm
was retracted distally and the spine was evaluated and the tumor
site was easily palpable as a prominent bone just at the
attachment of the diaphragm.
The pleura was divided along the lateral spine above the level of
the diaphragm. The diaphragm was then taken down along its
peripheral margin on the left. It was reflected in an anterior
direction. The pleura was divided as mentioned along the lateral
part of the spine and the thoracic level and the iliopsoas muscle
was split at its proximal point of attachment. The lateral
aspect of the spine was so exposed and the segmentals at T11,
T12, and L1 were identified and ligated and clipped with vascular
clamps.
The C-arm was used one more time to confirm the exact anatomy and
it was noted that there was a large expansile area of the spine
which appeared to be the vertebra of L1. The disk space at L1-L2
was entered and then subsequently the tissues were debrided to
include disk space at the L1-L2 and disk space at T12-L1 and
ultimately disk space at T11-T12.
The bone that was around the peripheral margin of L1 was removed.
The T12 vertebra was also taken down. The T12 vertebra was
remarkable for the presence of a collection of tumor material in
the inferior and posterior part of the body more to the left of
midline and this was debrided and sent for pathologic
examination. There was tumor noted within the body of L1 also
which was saved and sent for examination. The dissection was
carefully carried out to include removal of the disks in the
evacuation site as well as the vertebral body bone that remained
in the tumor. The tumor that was in the spinal canal itself was
initially left in place. Ultimately once a thorough debridement
was performed, it was possible to begin to isolate that tumor.
The posterior part of the wall of T12 was also removed in order
to better access the normal anatomy of the epidural space and the
dissection was carried distally through the disk space of T12-L1.
Ultimately the massive tumor that was within the canal was
gently retrieved from the spinal canal using a curette with a 4
direction movement. This lobular collection of tissue was sent
to the lab also for analysis.
At the conclusion of this, there was a very wide decompression
that had taken place between the upper endplate of T12 to the
lower endplate of L1, including the disk spaces at the top and
bottom of this dissection site.
The site for insertion of the cage was further prepared by
removing any peripheral prominent tissue including bone. The
space was then measured and it was felt a 60 mm opening was
appropriate. The appropriate cage for the Danek system was
selected. It was packed with bone and then inserted within the
defect site and was distracted. It actually obtained very good
compression within the corpectomy site. When it appeared to be
fully distracted, the anterior plate was prepared. A large bolt
was inserted into the body of T11 and another into L2 after using
an awl to create the screw site. A tapping was performed and
measurement performed and 35 mm screws were inserted. These were
then used to secure the plate to the lateral part of the spine.
Just prior to inserting the plate by the way, the rib graft that
had previously been harvested was shortened and prepared and then
inserted as a strut along the side of the cage. In addition, the
remaining rib graft that was of shorter length was morselized
completely and packed in the space anterior to the cage.
Again, the plate was applied. Intraoperative films were
obtained, confirming appropriate positioning of the hardware.
The wound was irrigated copiously. Repair was then carried out
of the pleura along the spine and the diaphragm using a running
#1 Vicryl suture.
The chest tubes were then inserted through separate stab
incisions above the level of the surgical incision. The chest
tubes were tunneled in a cephalad direction and through a
separate interspace between the ribs. One was placed in the
apical portion of the chest and the other was placed in a curved
manner down into the surgical dissection field.
The ribs were then reapproximated with the rib reapproximator and
#5 Ethibond suture was used at 4 sites to hold the ribs together.
Closure of the chest wall was then carried out in layers with
running #1 Vicryl suture. 2-0 Vicryl suture was used in the
subcutaneous layer, and skin was closed with running 4-0 Vicryl
subcuticular stitch. Dermabond, Steri-Strips, sterile dressings
were applied. The patient was placed back into a supine position
on the hospital bed, and the suction for the chest tubes applied.
She was extubated and taken to recovery room in stable
condition. The sponge and needle counts were correct at the end
of the procedure.
POSTOPERATIVE DIAGNOSIS:
1. Metastatic cancer T12 and L1.
2. Pathologic fracture L1.
3. Severe spinal cord compression L1.
4. Severe back and right thigh pain.
OPERATION PERFORMED:
1. Anterior T12 and L1 corpectomies.
2. Anterior decompression spinal cord T12-L1.
3. Anterior reconstruction with cage and anterior plate fixation
at T11 to L2.
4. Anterior fusion at the T11 to L2.
5. Local bone graft harvest through T10 rib.
6. Insertion of demineralized bone matrix allograft.
ANESTHESIA:
General.
COMPLICATIONS:
None.
DESCRIPTION OF OPERATION:
The patient was taken to the operating room and a general
anesthetic was obtained. She was placed in a right lateral
decubitus position. The beanbag positioner was used to maintain
the lateral position. An axillary roll was placed under the down
axilla. The knees were supported with pillows to avoid peroneal
nerve injury and the hips and knees were gently flexed. The
extremities were secured to the table. The body was flexed over
the table with the break in the table being approximately at the
mid flank level to bend the spine somewhat to the right. The
lateral chest was then prepped and draped in the usual sterile
fashion as was the abdomen and this was done after examining the
operative level with the C-arm and confirming the incision site.
The prep and drape was completed per usual protocol and after a
time-out was performed and antibiotics were confirmed
administered, an incision was created in an oblique manner over
the left lower thoracic area. The skin and subcutaneous tissues
were divided. The rib was identified and exposed
subperiosteally. The rib was stripped of soft tissues and then
sectioned at its proximal end with a rib cutter and distally it
was removed from its soft tissue attachment. It appeared to be a
floating rib but it was the T10 rib it turned out.
This appeared to allow visualization of the pleura. With
inspection, it appeared that the best approach would be through
the chest and therefore the pleural was divided. The diaphragm
was retracted distally and the spine was evaluated and the tumor
site was easily palpable as a prominent bone just at the
attachment of the diaphragm.
The pleura was divided along the lateral spine above the level of
the diaphragm. The diaphragm was then taken down along its
peripheral margin on the left. It was reflected in an anterior
direction. The pleura was divided as mentioned along the lateral
part of the spine and the thoracic level and the iliopsoas muscle
was split at its proximal point of attachment. The lateral
aspect of the spine was so exposed and the segmentals at T11,
T12, and L1 were identified and ligated and clipped with vascular
clamps.
The C-arm was used one more time to confirm the exact anatomy and
it was noted that there was a large expansile area of the spine
which appeared to be the vertebra of L1. The disk space at L1-L2
was entered and then subsequently the tissues were debrided to
include disk space at the L1-L2 and disk space at T12-L1 and
ultimately disk space at T11-T12.
The bone that was around the peripheral margin of L1 was removed.
The T12 vertebra was also taken down. The T12 vertebra was
remarkable for the presence of a collection of tumor material in
the inferior and posterior part of the body more to the left of
midline and this was debrided and sent for pathologic
examination. There was tumor noted within the body of L1 also
which was saved and sent for examination. The dissection was
carefully carried out to include removal of the disks in the
evacuation site as well as the vertebral body bone that remained
in the tumor. The tumor that was in the spinal canal itself was
initially left in place. Ultimately once a thorough debridement
was performed, it was possible to begin to isolate that tumor.
The posterior part of the wall of T12 was also removed in order
to better access the normal anatomy of the epidural space and the
dissection was carried distally through the disk space of T12-L1.
Ultimately the massive tumor that was within the canal was
gently retrieved from the spinal canal using a curette with a 4
direction movement. This lobular collection of tissue was sent
to the lab also for analysis.
At the conclusion of this, there was a very wide decompression
that had taken place between the upper endplate of T12 to the
lower endplate of L1, including the disk spaces at the top and
bottom of this dissection site.
The site for insertion of the cage was further prepared by
removing any peripheral prominent tissue including bone. The
space was then measured and it was felt a 60 mm opening was
appropriate. The appropriate cage for the Danek system was
selected. It was packed with bone and then inserted within the
defect site and was distracted. It actually obtained very good
compression within the corpectomy site. When it appeared to be
fully distracted, the anterior plate was prepared. A large bolt
was inserted into the body of T11 and another into L2 after using
an awl to create the screw site. A tapping was performed and
measurement performed and 35 mm screws were inserted. These were
then used to secure the plate to the lateral part of the spine.
Just prior to inserting the plate by the way, the rib graft that
had previously been harvested was shortened and prepared and then
inserted as a strut along the side of the cage. In addition, the
remaining rib graft that was of shorter length was morselized
completely and packed in the space anterior to the cage.
Again, the plate was applied. Intraoperative films were
obtained, confirming appropriate positioning of the hardware.
The wound was irrigated copiously. Repair was then carried out
of the pleura along the spine and the diaphragm using a running
#1 Vicryl suture.
The chest tubes were then inserted through separate stab
incisions above the level of the surgical incision. The chest
tubes were tunneled in a cephalad direction and through a
separate interspace between the ribs. One was placed in the
apical portion of the chest and the other was placed in a curved
manner down into the surgical dissection field.
The ribs were then reapproximated with the rib reapproximator and
#5 Ethibond suture was used at 4 sites to hold the ribs together.
Closure of the chest wall was then carried out in layers with
running #1 Vicryl suture. 2-0 Vicryl suture was used in the
subcutaneous layer, and skin was closed with running 4-0 Vicryl
subcuticular stitch. Dermabond, Steri-Strips, sterile dressings
were applied. The patient was placed back into a supine position
on the hospital bed, and the suction for the chest tubes applied.
She was extubated and taken to recovery room in stable
condition. The sponge and needle counts were correct at the end
of the procedure.