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spinal surgery help?


North East Kansas
Best answers
I am confused in how to code this procedure - can someone help me please?

The patient was placed in a semi prone position under general anesthesia. A lateral incision was made at approximately the level of L4-5 on C-arm fluoroscopy above the iliac crest on the left side. We dissected through the subcutaneous tissue into the psoas muscle with neural monitoring guidance using multiple dilators to expose the disk space at L4-5. Oncethe disk space had been exposed, we then used a disk blade to incise the disk space and then multiple pituitary rongeurs as well as disk shavers were used to remove the disk material at L4-5. After adequate decompression had been obtained, we then placedthe intervertebral biomechanical device at L4-5 with DBX material in it. This was confirmed under fluoroscopy, and we then removed the dilators and ensured the neural monitoring did not show any EMG spikes. We then reapproximated the skin fascia using Vicryl stitches and the skin was closed using staples.

The patient was then turned over into a prone position and then her back was prepped and draped in the usual surgical fashion. We then made a stab incision at the level of the L4 pedicle posteriorly and placed a K-wire with a Jamshidi needle into the pedicle space at L4 and this was guided under AP and lateral fluoroscopy into the pedicle up to the vertebral body. A K-wire was left in place and was then followed by a hand tap, followed by a pedicle screw. Similar procedures were performed at L5 on the right as well as L4 and L5 on the left. Percutaneous rods were placed under fluoroscopic guidance from the L4 to L5 pedicle screws and was secured in position with the setscrews. We ensured adequate hemostasis and then placed the setscrew onto the rods. Once the pedicle screws had been secured with interconnecting rods we then reapproximated the skin incisions using Vicryl stitches and Dermabond.