tjaved
New
We had a patient who had a synovial cyst on both sides of the lumbar spine , severly adherent to the thecal sac. We would like opinions on how to code. He coded 63277-22. Is there a better way to code it? thanks in advance.
OPERATIVE INDICATION: The patient presented with symptoms of predominantly left leg pain with some right leg pain. The MRI scan revealed a synovial cyst extending into the neural foramen on the left and a larger cyst on the right. The patient had failed to respond to nonsurgical treatment. Flexion, extension films revealed no instability of the spine. She was therefore recommended to undergo bilateral laminectomy and excision of synovial cyst. Prior to the
operation, the operative procedure, alternatives, potential risks of surgery were discussed at length with the patient, including, but not limited to infection, nerve injury, CSF leak, recurrence of the cyst, spinal instability requiring a fusion surgery at a later date. The patient indicated understanding of the above and wished to proceed with surgery.
OPERATIVE NOTE: The patient was taken to the operating room awake. She was given general endotracheal anesthesia. She was given preoperative antibiotics and Decadron. She was then carefully placed in the prone position on 2 chest rolls. Bony prominences were padded and taped into position. The lumbar area was then clipped and prepped with Betadine soap, painted with Hibiscrub and draped in the usual sterile fashion.
The patient's name, identity, site of operation was confirmed with the circulating nurse. Using the C-arm, the L4-L5 level was identified on the skin. Marcaine 0.25% with 1: 200000 epinephrine infiltrated into the
subcutaneous area. A 2-cm incision was made left of the midline. Incision carried down through the lumbar fascia, and this was incised. The tubular dilators were then docked onto the lamina of L4-5, followed by placement of a 6 cm x 18 mm tubular retractor over the L4-5 level. The level was confirmed on the AP and lateral x-ray. Operating microscope was draped and brought in the operative field for
microsurgical dissection of fine neural structures. Working through the microscope, the inferior and superior aspect of the lamina of L4 and L5 was thinned. Additional bone removal was performed on the left since the cyst extended superiorly up to the pedicle of L3. The bone and ligament removal was performed and the cyst was visible lateral to
the dura and quite adherent to the dura. This was opened and drained and then the dura along with the ligament was carefully dissected and removed in a piecemeal fashion. The L4 nerve root was identified and decompression of the nerve root was performed since the cyst extended up superiorly to that level. The L5 nerve root was also completely decompressed. Bleeding was controlled using Gelfoam and thrombin powder. The table was then rotated away from me and the tubular retractor was directed towards the right side. Working towards the right, the bone was removed over the cyst. A large cyst was present, which was causing marked compression of the thecal sac. The cyst was
opened to drain the cyst of gelatinous material. The cyst was then carefully dissected away from the dura using microdissection and removed and the spinal canal was completely decompressed along with the L4 and L5 nerve roots bilaterally. Once the decompression had been
performed, bleeding was controlled using Gelfoam and thrombin powder. Wound was copiously irrigated with antibiotic solution. A piece of Gelfoam was laid over the laminectomy site. The retractor was gradually withdrawn while obtaining hemostasis. Lumbar fascia was reapproximated using 2-0 Vicryl, subcutaneous layer reapproximated using 2-0 Vicryl. Skin was closed using staples. The wound was cleaned and dressed with Xeroform dry gauze. Sponge and instrument count was correct.
OPERATIVE INDICATION: The patient presented with symptoms of predominantly left leg pain with some right leg pain. The MRI scan revealed a synovial cyst extending into the neural foramen on the left and a larger cyst on the right. The patient had failed to respond to nonsurgical treatment. Flexion, extension films revealed no instability of the spine. She was therefore recommended to undergo bilateral laminectomy and excision of synovial cyst. Prior to the
operation, the operative procedure, alternatives, potential risks of surgery were discussed at length with the patient, including, but not limited to infection, nerve injury, CSF leak, recurrence of the cyst, spinal instability requiring a fusion surgery at a later date. The patient indicated understanding of the above and wished to proceed with surgery.
OPERATIVE NOTE: The patient was taken to the operating room awake. She was given general endotracheal anesthesia. She was given preoperative antibiotics and Decadron. She was then carefully placed in the prone position on 2 chest rolls. Bony prominences were padded and taped into position. The lumbar area was then clipped and prepped with Betadine soap, painted with Hibiscrub and draped in the usual sterile fashion.
The patient's name, identity, site of operation was confirmed with the circulating nurse. Using the C-arm, the L4-L5 level was identified on the skin. Marcaine 0.25% with 1: 200000 epinephrine infiltrated into the
subcutaneous area. A 2-cm incision was made left of the midline. Incision carried down through the lumbar fascia, and this was incised. The tubular dilators were then docked onto the lamina of L4-5, followed by placement of a 6 cm x 18 mm tubular retractor over the L4-5 level. The level was confirmed on the AP and lateral x-ray. Operating microscope was draped and brought in the operative field for
microsurgical dissection of fine neural structures. Working through the microscope, the inferior and superior aspect of the lamina of L4 and L5 was thinned. Additional bone removal was performed on the left since the cyst extended superiorly up to the pedicle of L3. The bone and ligament removal was performed and the cyst was visible lateral to
the dura and quite adherent to the dura. This was opened and drained and then the dura along with the ligament was carefully dissected and removed in a piecemeal fashion. The L4 nerve root was identified and decompression of the nerve root was performed since the cyst extended up superiorly to that level. The L5 nerve root was also completely decompressed. Bleeding was controlled using Gelfoam and thrombin powder. The table was then rotated away from me and the tubular retractor was directed towards the right side. Working towards the right, the bone was removed over the cyst. A large cyst was present, which was causing marked compression of the thecal sac. The cyst was
opened to drain the cyst of gelatinous material. The cyst was then carefully dissected away from the dura using microdissection and removed and the spinal canal was completely decompressed along with the L4 and L5 nerve roots bilaterally. Once the decompression had been
performed, bleeding was controlled using Gelfoam and thrombin powder. Wound was copiously irrigated with antibiotic solution. A piece of Gelfoam was laid over the laminectomy site. The retractor was gradually withdrawn while obtaining hemostasis. Lumbar fascia was reapproximated using 2-0 Vicryl, subcutaneous layer reapproximated using 2-0 Vicryl. Skin was closed using staples. The wound was cleaned and dressed with Xeroform dry gauze. Sponge and instrument count was correct.