abenn
New
If anyone has any experience with neurosurgery, we have just started performing cases like the one I have added below, and we could use some advice. We are unsure if we should be coding 27280 alone, 22848 alone, or both of them. Thank you in advance!
PREOPERATIVE DIAGNOSES:
1. Status post lumbar decompression L2 through L5.
2. Instrumented spinal fusion L1 through L5.
3. Posterior lumbar interbody fusion with spacers L4/L5.
4. Postoperative fracture L5 bilateral pedicles with displacement of devices L4/L5.
POSTOPERATIVE DIAGNOSES:
1. Status post lumbar decompression L2 through L5.
2. Instrumented spinal fusion L1 through L5.
3. Posterior lumbar interbody fusion with spacers L4/L5.
4. Postoperative fracture L5 bilateral pedicles with displacement of devices L4/L5.
PROCEDURES PERFORMED:
1. Retrieval interbody devices, L4/L5.
2. Re-instrumentation L5 bilaterally.
3. Instrumented iliac fixation and sacral fixation with harvest of autograft at same incision.
4. Instrumented autograft arthrodesis with extension from the L1 now through Ilium.
DRAINS: Bilateral midline subfascial space tunneled to the cephalad end.
SPECIMENS: None.
FINDINGS: A fracture of L5 greater on the right than the left, re-instrumentation with fixation at L5. No dural breech, unilateral interbody prosthetic device replaced, 13 mm high in the left and not replaced on the right.
ESTIMATED BLOOD LOSS: 200 mL.
INDICATION FOR OPERATION: The patient is a 66-year-old man, who about a week ago underwent a routine lumbar decompression on account of terrible spinal stenosis and degenerative offset of L4-L5. Interbody devices were used at 9 mm to support the L4-L5 space with autograft as well and the patient did well postoperatively with nice return of leg function and without pain. After that procedure, his course was then complicated by evolving back pain, to know particular fault of his own such as fall, etc. and then somewhere about a week out underwent lumbar spine CT. This revealed what appeared to be lumbar fractures of the L5 pedicles bilaterally now through the vertebral bodies. Risks, complications, goals, objective of an extension surgery were discussed with him and his wife, and I was once again involved to assist with this lumbosacral iliac fixation technique. Bleeding, infection, failure again of the bony architecture at the sacrum, especially was discussed and the need for iliac fixation in this particular setting was also outlined. Under those auspices, then we moved forward with surgery to go ahead and try to re-instrument across the fracture L5 to remove and/or replace the interbody prosthetic devices, which were maintaining alignment between L4 and L5 and then extend this to the ilium to gain greater fixation. Soft bone and some of the porous abnormalities of bone associated with these fractures were discussed and some of our plans for trying to alleviate any further complications by attaching to the nonporous ilium was discussed.
TECHNICAL DESCRIPTION FOR SURGERY: The patient was brought to the operating room in the morning hours of 15, December 2017, rapidly and smoothly induced. Once he was intubated under effects of inhalation anesthesia, he was placed in prone position, given a Foley catheter already, large-bore IVs, arterial line, area of the previous operation had all the sutures removed. It was cleaned with a combination of Hibiclens soap, alcohol and then a double prepping with alcohol plus Hibiclens again for preparation. Once this was done then and sterile barriers have been applied and films have been demonstrated in the room and the plan was once again outlined and a meaningful timeout was conducted. We then moved forward to quickly with operation. At that point, then 2 incisions were opened up just right of midline about 5 fingerbreadths over what I believed to be PSIS and first on the right with a 10 blade knife and then on the left and epifascial dissections were carried on both sides with monopolar coagulators and black Allen Cobb and then the PSIS was entered bilaterally then first on the right and then on the left and a subperiosteal dissection was carried out down the ilium until the sciatic notch was observed and then palpated easily. Once this had been done, then on the right, we then went back and removed the Gelfoam from the bone graft donor site and made a head went down to what was I believed to be a solid bone of the marrow of the ilium on the right and this whole process was carried out on the left as well when there was no donor site there and therefore we marked out what we believed to be the bottom two thirds of the PSIS complex and placed straight curettes into that area and then once that was completed, called for a AP projection x-ray to make certain that we were directly over what was going to be the column of the ilium as it is the superior boundary of the sciatic notch. Once those adjustments have been made, we then went ahead and opened the midline spine wound with a 10 blade knife, removed all the sutures on the way down and opened the fascia and drained out the retained seroma and then identified the main dural tube and then irrigated it vigorously trying to be careful to observe his caution and remove his little bone graft as possible. We then went back and took the horizontal cross-links off and then go ahead and took the 2 vertical rods off and then at that point, went back and began the process of placing in what appeared to be a fairly uneventful exploration of the posterior lumbar interbody fusion site of L4-L5. We could see the both of the cages were loose. The right one was removed and was not replaced and instead that tract was packed with bone. The left one was removed and replaced with a taller 13 mm device, which then buttressed against the fractured L5 very tightly. Once that was done, then we went about the business of calling for O-arm. AP and lateral projection x-rays were acquired. CT data was accumulated and then navigation was made ready after the reference arc had been placed on to the sacrum. We then brought the business of guiding in 80 mm x 10 mm diameter screws into the column of the ilium first on the right then on the left and then removed bone with an osteotome of one thumb's breadth in front of the ilium entry site and then all the bone was taken around the screw head and brought it down to a level area with the sacrum. Once this was done, then we went about the business of passing bicortical sacral screws at about 8 mm x 65 and once those have been placed in using standard Steffee technique by guiding those awls down and then tapping them bicortically and then placing in screws, we then brought the business of vigorous irrigation and then took cobalt chrome rods to replace the titanium rods and contoured them appropriately using rodded connectors and then placed the iliac fixation bolts to close the end iliac fixation bolts to a horizontally oriented rodded connector and then that rodded connector was then placed onto the rod itself, which would be vertically oriented and then contoured appropriately and attached L1 through ilium. With all the devices tightened, horizontally oriented connectors were placed on. Bone graft was then taken and mixed and placed into the posterior lateral gutters of the ala of sacrum as well as L5 and then we began closure with benefit of a deep drain placed in a dual fashion and ran to be cephalad in with 0.0 Vicryl to muscle and fascia, 2.0 and 3.0 Vicryl to various layers of subcutaneous tissues and the same to be said for the hip donor site/ilium insertion sites and these were 0.0 Vicryls across the lumbosacral fascia and then 2.0 and 3.0 Vicryl to the various layers of subcutaneous tissues and a 3-0 nylon was used as was the midline with 3-0 nylon in a running locking fashion. Once this has been done, drains were then secured and then the patient was given a sterile dressing, turned into the supine position, taken to the recovery room and within 15 to 20 minutes had a normal blood pressure, i.e. 100 mmHg, heart rate just a bit high at 124 and a hemoglobin of 11.9 to 12. Postoperative CT was checked within the hour and found to be safe placement with no complications from the ilium all the way up to L1 and no hematomas.
PREOPERATIVE DIAGNOSES:
1. Status post lumbar decompression L2 through L5.
2. Instrumented spinal fusion L1 through L5.
3. Posterior lumbar interbody fusion with spacers L4/L5.
4. Postoperative fracture L5 bilateral pedicles with displacement of devices L4/L5.
POSTOPERATIVE DIAGNOSES:
1. Status post lumbar decompression L2 through L5.
2. Instrumented spinal fusion L1 through L5.
3. Posterior lumbar interbody fusion with spacers L4/L5.
4. Postoperative fracture L5 bilateral pedicles with displacement of devices L4/L5.
PROCEDURES PERFORMED:
1. Retrieval interbody devices, L4/L5.
2. Re-instrumentation L5 bilaterally.
3. Instrumented iliac fixation and sacral fixation with harvest of autograft at same incision.
4. Instrumented autograft arthrodesis with extension from the L1 now through Ilium.
DRAINS: Bilateral midline subfascial space tunneled to the cephalad end.
SPECIMENS: None.
FINDINGS: A fracture of L5 greater on the right than the left, re-instrumentation with fixation at L5. No dural breech, unilateral interbody prosthetic device replaced, 13 mm high in the left and not replaced on the right.
ESTIMATED BLOOD LOSS: 200 mL.
INDICATION FOR OPERATION: The patient is a 66-year-old man, who about a week ago underwent a routine lumbar decompression on account of terrible spinal stenosis and degenerative offset of L4-L5. Interbody devices were used at 9 mm to support the L4-L5 space with autograft as well and the patient did well postoperatively with nice return of leg function and without pain. After that procedure, his course was then complicated by evolving back pain, to know particular fault of his own such as fall, etc. and then somewhere about a week out underwent lumbar spine CT. This revealed what appeared to be lumbar fractures of the L5 pedicles bilaterally now through the vertebral bodies. Risks, complications, goals, objective of an extension surgery were discussed with him and his wife, and I was once again involved to assist with this lumbosacral iliac fixation technique. Bleeding, infection, failure again of the bony architecture at the sacrum, especially was discussed and the need for iliac fixation in this particular setting was also outlined. Under those auspices, then we moved forward with surgery to go ahead and try to re-instrument across the fracture L5 to remove and/or replace the interbody prosthetic devices, which were maintaining alignment between L4 and L5 and then extend this to the ilium to gain greater fixation. Soft bone and some of the porous abnormalities of bone associated with these fractures were discussed and some of our plans for trying to alleviate any further complications by attaching to the nonporous ilium was discussed.
TECHNICAL DESCRIPTION FOR SURGERY: The patient was brought to the operating room in the morning hours of 15, December 2017, rapidly and smoothly induced. Once he was intubated under effects of inhalation anesthesia, he was placed in prone position, given a Foley catheter already, large-bore IVs, arterial line, area of the previous operation had all the sutures removed. It was cleaned with a combination of Hibiclens soap, alcohol and then a double prepping with alcohol plus Hibiclens again for preparation. Once this was done then and sterile barriers have been applied and films have been demonstrated in the room and the plan was once again outlined and a meaningful timeout was conducted. We then moved forward to quickly with operation. At that point, then 2 incisions were opened up just right of midline about 5 fingerbreadths over what I believed to be PSIS and first on the right with a 10 blade knife and then on the left and epifascial dissections were carried on both sides with monopolar coagulators and black Allen Cobb and then the PSIS was entered bilaterally then first on the right and then on the left and a subperiosteal dissection was carried out down the ilium until the sciatic notch was observed and then palpated easily. Once this had been done, then on the right, we then went back and removed the Gelfoam from the bone graft donor site and made a head went down to what was I believed to be a solid bone of the marrow of the ilium on the right and this whole process was carried out on the left as well when there was no donor site there and therefore we marked out what we believed to be the bottom two thirds of the PSIS complex and placed straight curettes into that area and then once that was completed, called for a AP projection x-ray to make certain that we were directly over what was going to be the column of the ilium as it is the superior boundary of the sciatic notch. Once those adjustments have been made, we then went ahead and opened the midline spine wound with a 10 blade knife, removed all the sutures on the way down and opened the fascia and drained out the retained seroma and then identified the main dural tube and then irrigated it vigorously trying to be careful to observe his caution and remove his little bone graft as possible. We then went back and took the horizontal cross-links off and then go ahead and took the 2 vertical rods off and then at that point, went back and began the process of placing in what appeared to be a fairly uneventful exploration of the posterior lumbar interbody fusion site of L4-L5. We could see the both of the cages were loose. The right one was removed and was not replaced and instead that tract was packed with bone. The left one was removed and replaced with a taller 13 mm device, which then buttressed against the fractured L5 very tightly. Once that was done, then we went about the business of calling for O-arm. AP and lateral projection x-rays were acquired. CT data was accumulated and then navigation was made ready after the reference arc had been placed on to the sacrum. We then brought the business of guiding in 80 mm x 10 mm diameter screws into the column of the ilium first on the right then on the left and then removed bone with an osteotome of one thumb's breadth in front of the ilium entry site and then all the bone was taken around the screw head and brought it down to a level area with the sacrum. Once this was done, then we went about the business of passing bicortical sacral screws at about 8 mm x 65 and once those have been placed in using standard Steffee technique by guiding those awls down and then tapping them bicortically and then placing in screws, we then brought the business of vigorous irrigation and then took cobalt chrome rods to replace the titanium rods and contoured them appropriately using rodded connectors and then placed the iliac fixation bolts to close the end iliac fixation bolts to a horizontally oriented rodded connector and then that rodded connector was then placed onto the rod itself, which would be vertically oriented and then contoured appropriately and attached L1 through ilium. With all the devices tightened, horizontally oriented connectors were placed on. Bone graft was then taken and mixed and placed into the posterior lateral gutters of the ala of sacrum as well as L5 and then we began closure with benefit of a deep drain placed in a dual fashion and ran to be cephalad in with 0.0 Vicryl to muscle and fascia, 2.0 and 3.0 Vicryl to various layers of subcutaneous tissues and the same to be said for the hip donor site/ilium insertion sites and these were 0.0 Vicryls across the lumbosacral fascia and then 2.0 and 3.0 Vicryl to the various layers of subcutaneous tissues and a 3-0 nylon was used as was the midline with 3-0 nylon in a running locking fashion. Once this has been done, drains were then secured and then the patient was given a sterile dressing, turned into the supine position, taken to the recovery room and within 15 to 20 minutes had a normal blood pressure, i.e. 100 mmHg, heart rate just a bit high at 124 and a hemoglobin of 11.9 to 12. Postoperative CT was checked within the hour and found to be safe placement with no complications from the ilium all the way up to L1 and no hematomas.