melissa.reed22
Contributor
I'm having trouble with coding this correctly. I've found code 63707 for the repair of dural leakage, but am stuck with the codes for debridement and intraoperative cultures. Here is the op note. Also help with the dx codes would be appreciated as well.
Preoperative Diagnoses:
1) Probable dural tear with continued drainage.
2) Postoperative wound infection.
Postoperative Diagnoses:
1) Probable dural tear with continued drainage.
2) Postoperative wound infection.
Procedure:
1) Repair dural leakage with placement of Duragen patch and Tisseel.
2) Debridement and irrigation down to bone.
3) Intraoperative cultures.
Estimated blood loss: 200 mL
Anesthesia: General
Indications: (Patient) is an 87-year-old gentleman who had a right leg radiculopathy secondary to herniated disk. He underwent a discectomy about 2 weeks ago and had a small dural tear that was fixed with primary closure. He did well with mobilizing well until Friday - 3 days ago. He developed a headache, nausea, vomiting, and fevers. He also developed drainage from his back. Due to the symptoms, he was taken to the operating room today for exploration of wound debridement and irrigation.
Prior procedures temperature was noted to be 39 degrees centigrade. The preoperative antibiotics had already been given. Intraoperative cultures were taken.
Description of procedure:
General anesthesia was given. The patient was placed prone on a well padded Jackson table. The spine was prepped and draped in the usual sterile fashion. The previous incision was incised. There was about 10, cloudy dural fluid that was aspirated just below the skin. Cultures were taken immediately. this did not appear to be normal-appearing CSF. It was cloudy consistent with an infected seroma.
The incision was expanded distally and the debridement adhesions taken down all the way to the bone. The paraspinal muscles were debrided using a Kerrison rongeur and the remaining bony edges around the previous laminectomy site were expanded proximally and distally to allow excellent visualization of previous dural repair. I inspected the previous dural repair. There were several stitches in place. There was no evidence of failure of any of the stitches. There was a small area. when probed resulted in a small leakage of spinal fluid. This was then reinforced with 3 or 4 external sutures. The area was completely irrigated to include the disk space with at least 1 L of antibiotic normal saline solution.
I then reinforced the dura closure by placing Tisseel on the undersurface of the dura and nerve root and then reinforcing that with a 1 x 1 Duragen patch followed by more Tisseel over top of the dura resulting in Walter watertight closure. There was no evidence of any dural leak after this.
The incision was closed in layers using interrupted and running #1 Vicryl sutures to approximate the deep fascia, 0 and 2-0 Vicryl sutures for the deep fat layer and the skin was closed using a running Monocryl suture. Steri-Strips as well as a sterile bulky back dressing was applied. The patient's anesthetic was reversed and he was taken to the recovery room in good and stable condition.
Due to the suspected infection, infectious disease has been consulted to follow up cultures as well as recommend IV antibiotics. I do believe this patient needs 2 weeks worth at minimum antibiotics followed by 6 weeks or oral antibiotics.
As to treatment of the dural tear, although there was no obvious drainage noted during the repair. This clearly has a small leak, that is the seroma. I did reince it and then patched as noted above. I do think it would benefit this patient if they remained supine for 72 hours. There is a superficial drain placed. He will be immobilized 72 hours and if he does not have a headache or any increased drainage, then the drain will be pulled and he will be discharged back to his rehabilitation facility. I discussed all these findings with the family.
After the procedure, the sponge count was correct and verified. Prior to this procedure, an intraoperative time-out was undertaken and all variables were confirmed.
Preoperative Diagnoses:
1) Probable dural tear with continued drainage.
2) Postoperative wound infection.
Postoperative Diagnoses:
1) Probable dural tear with continued drainage.
2) Postoperative wound infection.
Procedure:
1) Repair dural leakage with placement of Duragen patch and Tisseel.
2) Debridement and irrigation down to bone.
3) Intraoperative cultures.
Estimated blood loss: 200 mL
Anesthesia: General
Indications: (Patient) is an 87-year-old gentleman who had a right leg radiculopathy secondary to herniated disk. He underwent a discectomy about 2 weeks ago and had a small dural tear that was fixed with primary closure. He did well with mobilizing well until Friday - 3 days ago. He developed a headache, nausea, vomiting, and fevers. He also developed drainage from his back. Due to the symptoms, he was taken to the operating room today for exploration of wound debridement and irrigation.
Prior procedures temperature was noted to be 39 degrees centigrade. The preoperative antibiotics had already been given. Intraoperative cultures were taken.
Description of procedure:
General anesthesia was given. The patient was placed prone on a well padded Jackson table. The spine was prepped and draped in the usual sterile fashion. The previous incision was incised. There was about 10, cloudy dural fluid that was aspirated just below the skin. Cultures were taken immediately. this did not appear to be normal-appearing CSF. It was cloudy consistent with an infected seroma.
The incision was expanded distally and the debridement adhesions taken down all the way to the bone. The paraspinal muscles were debrided using a Kerrison rongeur and the remaining bony edges around the previous laminectomy site were expanded proximally and distally to allow excellent visualization of previous dural repair. I inspected the previous dural repair. There were several stitches in place. There was no evidence of failure of any of the stitches. There was a small area. when probed resulted in a small leakage of spinal fluid. This was then reinforced with 3 or 4 external sutures. The area was completely irrigated to include the disk space with at least 1 L of antibiotic normal saline solution.
I then reinforced the dura closure by placing Tisseel on the undersurface of the dura and nerve root and then reinforcing that with a 1 x 1 Duragen patch followed by more Tisseel over top of the dura resulting in Walter watertight closure. There was no evidence of any dural leak after this.
The incision was closed in layers using interrupted and running #1 Vicryl sutures to approximate the deep fascia, 0 and 2-0 Vicryl sutures for the deep fat layer and the skin was closed using a running Monocryl suture. Steri-Strips as well as a sterile bulky back dressing was applied. The patient's anesthetic was reversed and he was taken to the recovery room in good and stable condition.
Due to the suspected infection, infectious disease has been consulted to follow up cultures as well as recommend IV antibiotics. I do believe this patient needs 2 weeks worth at minimum antibiotics followed by 6 weeks or oral antibiotics.
As to treatment of the dural tear, although there was no obvious drainage noted during the repair. This clearly has a small leak, that is the seroma. I did reince it and then patched as noted above. I do think it would benefit this patient if they remained supine for 72 hours. There is a superficial drain placed. He will be immobilized 72 hours and if he does not have a headache or any increased drainage, then the drain will be pulled and he will be discharged back to his rehabilitation facility. I discussed all these findings with the family.
After the procedure, the sponge count was correct and verified. Prior to this procedure, an intraoperative time-out was undertaken and all variables were confirmed.