tabithal
Contributor
Patient initially presented to an outside provider who performed a biopsy of this mass. Immediately after the biopsy, the patient started feeling significant pain, burning, and paresthesias in the thumb and index finger. The mass is directly over the dorsal sensory branch of the radial nerve. He requested completion excision of this schwannoma as well as exploration of the dorsal sensory branches of the radial nerve.
We discussed multiple options for treatment. I expressed that it would be very likely that this nerve is very tangled in this schwannoma and that it may have been damaged by the biopsy. As a result we may have to reconstruct this nerve or perform an extensive neurolysis. He expressed understanding of this and agreed to proceed. We reviewed the risks which include infection, bleeding, seroma, hematoma, persistent pain in the nerve distribution, numbness in the nerve distribution, recurrence of the schwannoma, and wound healing problems.
OPERATIVE PROCEDURE: patient was brought to the operating room and placed on the table in the supine position. His left hand was extended on the hand table. General anesthesia was achieved with an LMA. Once this was performed, his hand was prepped and draped in the standard sterile fashion for hand surgery. Time out was performed verifying the patient identity, procedure, and consent. Once this was done, I designed a longitudinal incision directly over the schwannoma extending both proximally and distally. I exsanguinated the upper extremity with an Esmarch bandage and raised the tourniquet to 250 mmHg. Once this was done I incised the skin with a #15 blade. I then used meticulous dissection technique to isolate the dorsal sensory branch of the radial nerve as it was emanating from the arm next to the brachioradialis. I then proceeded to identify the branches of the nerve distally at the base of the thumb. The area around the schwannoma itself was very scarred in. The schwannoma was about 3 cm in diameter. After very meticulous dissection of all the nerve branches, I identified 3 large nerve branches from the dorsal sensory nerve. The 2 largest branches were going directly towards the schwannoma.
At this point, I brought in the operating room microscope to complete the dissection. I performed an internal neurolysis of the dorsal sensory nerve to isolate these 2 nerve branches. The first nerve branch was scarred down to the lower portion of the schwannoma. However, using careful internal neurolysis under the operating room microscope, I was able to separate the fascicles of this first branch. I also separated these branches from the surrounding scar tissue. I then turned my attention to the second sensory nerve branch headed towards the schwannoma. This nerve branch was going directly into the center of the schwannoma. I did not feel that it was possible to separate these fascicles from the schwannoma. As a result I completely excised this segment of nerve including the schwannoma as a whole. This left a 3 cm nerve gap. Therefore I turned my attention to reconstruction of this nerve. I used a 2 mm x 5 cm Axogen nerve allograft to reconstruct this. I trimmed this nerve to the exact 3 cm required for a tension-free repair. Once this was done I inset the nerve allograft into the desired location and sewed it to the dorsal sensory branch under the operating room microscope. I used #9-0 suture and placed approximately 6 epineurial stitches both proximally and distally. In order to minimize scarring around both this nerve and the previously neuro lysed nerve branch, I used an Axogen and nerve wrap around both individually.
Once this was done I turned my attention to the skin closure. First I irrigated the wound with normal saline and then closed the skin in layers. The dermis was closed with 4-0 Monocryl. The epidermis was closed with a running 4-0 Monocryl. I then applied a Xeroform and a dry sterile dressing and wrap. I then applied a short arm plaster splint. For pain control, I injected 5 cc of a 1:1 mix of lidocaine and Marcaine with epi subcutaneously. The patient was then awoken from anesthesia in stable condition.
My physician wants to code:
Internal Neurolysis ? 64727
Schwannoma excision ? 64790
Suture of nerve ? 64834 (Or should I use 64910 since I used an allograft?)
Microscope (not bundled with suture of nerve) ? 69990
Splint ? 29075
Can someone please help with this??
We discussed multiple options for treatment. I expressed that it would be very likely that this nerve is very tangled in this schwannoma and that it may have been damaged by the biopsy. As a result we may have to reconstruct this nerve or perform an extensive neurolysis. He expressed understanding of this and agreed to proceed. We reviewed the risks which include infection, bleeding, seroma, hematoma, persistent pain in the nerve distribution, numbness in the nerve distribution, recurrence of the schwannoma, and wound healing problems.
OPERATIVE PROCEDURE: patient was brought to the operating room and placed on the table in the supine position. His left hand was extended on the hand table. General anesthesia was achieved with an LMA. Once this was performed, his hand was prepped and draped in the standard sterile fashion for hand surgery. Time out was performed verifying the patient identity, procedure, and consent. Once this was done, I designed a longitudinal incision directly over the schwannoma extending both proximally and distally. I exsanguinated the upper extremity with an Esmarch bandage and raised the tourniquet to 250 mmHg. Once this was done I incised the skin with a #15 blade. I then used meticulous dissection technique to isolate the dorsal sensory branch of the radial nerve as it was emanating from the arm next to the brachioradialis. I then proceeded to identify the branches of the nerve distally at the base of the thumb. The area around the schwannoma itself was very scarred in. The schwannoma was about 3 cm in diameter. After very meticulous dissection of all the nerve branches, I identified 3 large nerve branches from the dorsal sensory nerve. The 2 largest branches were going directly towards the schwannoma.
At this point, I brought in the operating room microscope to complete the dissection. I performed an internal neurolysis of the dorsal sensory nerve to isolate these 2 nerve branches. The first nerve branch was scarred down to the lower portion of the schwannoma. However, using careful internal neurolysis under the operating room microscope, I was able to separate the fascicles of this first branch. I also separated these branches from the surrounding scar tissue. I then turned my attention to the second sensory nerve branch headed towards the schwannoma. This nerve branch was going directly into the center of the schwannoma. I did not feel that it was possible to separate these fascicles from the schwannoma. As a result I completely excised this segment of nerve including the schwannoma as a whole. This left a 3 cm nerve gap. Therefore I turned my attention to reconstruction of this nerve. I used a 2 mm x 5 cm Axogen nerve allograft to reconstruct this. I trimmed this nerve to the exact 3 cm required for a tension-free repair. Once this was done I inset the nerve allograft into the desired location and sewed it to the dorsal sensory branch under the operating room microscope. I used #9-0 suture and placed approximately 6 epineurial stitches both proximally and distally. In order to minimize scarring around both this nerve and the previously neuro lysed nerve branch, I used an Axogen and nerve wrap around both individually.
Once this was done I turned my attention to the skin closure. First I irrigated the wound with normal saline and then closed the skin in layers. The dermis was closed with 4-0 Monocryl. The epidermis was closed with a running 4-0 Monocryl. I then applied a Xeroform and a dry sterile dressing and wrap. I then applied a short arm plaster splint. For pain control, I injected 5 cc of a 1:1 mix of lidocaine and Marcaine with epi subcutaneously. The patient was then awoken from anesthesia in stable condition.
My physician wants to code:
Internal Neurolysis ? 64727
Schwannoma excision ? 64790
Suture of nerve ? 64834 (Or should I use 64910 since I used an allograft?)
Microscope (not bundled with suture of nerve) ? 69990
Splint ? 29075
Can someone please help with this??