tmyers1989
New
Need help with CPT for this spinal surgery - I came up with 22633, 22634, 63047, 22842, 20931, 20936. Any suggestions would be appreciated.
Preoperative diagnosis: lumbar stenosis L2-3, L3-4, L4-5, grade 1 spondylolisthesis L4-5, recurrent lumbar stenosis L4-5, degenerative disc disease, facet arthropathy, degenerative scoliosis
Postop diagnosis: same
Procedure: L2-3 lumbar laminectomy, L3-4 lumbar laminectomy, L4-5 revision lumbar laminectomy, L2-5 posterior instrumented fusion, L2-5 posteriolateral mass fusion with allograft, harvesting of bone graft from same incision, use of navigation and Stealth
BACKGROUND: Patient with lower back pain and pain radiating down lower extremity. Patient has failed all conservative treatment modalities. Risks and benefits of the surgical procedure was discussed with the patient. Risks including but not limited to infection, blood loss, damage to blood vessels and nerve roots, need for more surgery, dural tear, PE, stroke, DVT, adjacent segment disease, revision surgery, death were discussed with the patient. Patient elected to proceed with the procedure
OPERATIVE FINDINGS: Severe lumbar stenosis L2-3, L3-4, recurrent lumbar stenosis L4-5 with severe scar tissue, facet arthropathy, grade 1 degenerative spondylolisthesis L4-5, obesity
OPERATIVE PROCEDURE:
The patient was placed on the operating table in the prone position on the Jackson table after induction of general anesthesia. X-ray was used to identify the lumbar L2-5 level. Lumbar spine was prepped and draped in sterile fashion. Standard time-out was called. Patient's operative site was confirmed by everyone. Midline incision was made. Dissection was carried throughout the subcutaneous layer and lumbar dorsal fascia was identified. Fascia was incised bilateral to the spinous process. Dissection was carried all the way down to the lamina and lamina of L L2-5 were dissected and identified. Facet joints were identified. Patient had a previous lumbar laminectomy at L4-5. We noticed that there was a lot of scar tissue around the previous laminectomy site on the right side. More than normal amount of procedure services were required to carefully dissect as not to injure the dural sac and to identify the previous lamina. We had to be extremely careful to identify the previous lamina and the facet joints due to previous scar tissue and laminectomy as well as due to patient's obesity. We were careful to make sure that the L1-2 joint capsule was not disrupted. We noticed that there was severe amount of facet arthropathy at L3-4, L4-5. We then proceeded with placement of pedicle screws. Stealth navigation was brought in. The clamp was placed on L5 spinous process. We then brought in the O-arm and did an intraoperative CT scan. Navigated gearshift was used to make a hole in the vertebral body. Patient had degenerative scoliosis which made the orientation of the pedicles extremely difficult along with previous scar tissue. The pedicle holes were then tapped with 5.5 mm tap and 6.5 mm x 50 mm screws were placed in the L2, L3, L4 pedicles. We placed 6.5 mm x 40 mm pedicle screws in the L5 pedicles bilaterally. We had excellent bite of the pedicle screws. AP and lateral x-rays were done which showed adequate positioning of the hardware. Neuromonitoring was used. The screws were checked with threshold above 20. Due to previous scar tissue and patient's BMI of more than 33 which necessitated increased amount of work for placement of the screws as well. We then proceeded with the decompression. Midline interspinous ligaments between L3-4, L4-5 spinous processes were rongeured. We then placed a lamina spreader to distract the L3-4 lamina. I proceeded with decompression of the lateral recess bilaterally. The curette was used to undermine the superior articular facet of L4 bilaterally. I used a Kerrison rongeur to decompress the lateral recess and the foramina by doing a partial facetectomy of the superior articular facets the L4 bilaterally. I used an osteotome to do a complete facetectomy of inferior L3 facets bilaterally to help us with the correction of the deformity as well as to help decompress the lateral recesses bilaterally as well as the laminas bilaterally. After we had adequate decompression of the lateral recess, with proceed with a complete laminectomy of L3 bilaterally. Complete laminectomy including the midline spinous process was removed using Kerrison rongeur's, bur. Patient had severe ligamentum hypertrophy which was causing the dural sac to curve due to osteophytes pushing on the sac. We carefully removed all of the osteophytes and spurs causing the curvature of the dural sac.. I used Kerrison rongeurs to remove the ligamentum hypertrophy and to fully decompress the dural sac. Woodson, nerve hook was used to confirm adequate decompression bilaterally. We noticed that the lateral recesses, foramens were adequately decompressed. I then turned our attention to decompression at L4-5 level. This took more than normal amount of procedural services due to patient having a previous laminectomy on the right side at L4. MRI showed severe stenosis bilaterally. We carefully identified the previous laminectomy site and used a Kerrison rongeur, Leksell rongeur to remove the midline spinous process. I used a curette to undermine the lamina and to separate the dural scar tissue from the undersurface of the lamina. Then used a Kerrison to do a complete laminectomy bilaterally. Patient had significant lateral recess stenosis from overgrowth of the superior articular facets of L5 bilaterally. I used #2 and #3 Kerrisons to remove the medial and the superior aspect of the L5 facets bilaterally to decompress the lateral recess as well as the neural foramens. Patient a lot of scar tissue on the right side against the dural sac. We had to carefully elevate the scar tissue from the dural sac to fully decompress the lateral recess. I felt we had adequate decompression at L4-5 level as well. We then proceeded to decompress the L2-3 level. I then did a laminectomy on the left side L2-3 level. I used the bur and Kerrison to do laminectomy of the left side L2 lamina. I was then able to undermine the ligamentum from the lamina and to decompress the midline as well as the right side of the undersurface of the lamina at L2 as well. Patient had moderate stenosis at that level. We felt we had adequate decompression and L2-3 level as well just using a unilateral laminectomy. The nerve roots were identified and were found to be free. The exiting and traversing nerve root were confirmed to be free using nerve hook. The navigated clamp was then removed from the L5 spinous process.
We then proceeded to obtain adequate hemostasis with Floseal, bipolar. We proceeded with the placement of 2 rods bilaterally. end caps were tightened. AP and lateral x-rays were done which showed adequate positioning of the hardware as well as improvement of the scoliotic curve. Transverse processes were then decorticated along with the facets. Allograft mixed with autograft bone graft was placed in the posterolateral gutters and around the facets and transverse processes for posterolateral fusion. Floseal was used to obtain adequate hemostasis. Wound was then thoroughly irrigated with Irrisept and saline solution. 2 medium Hemovac drain was placed.
1 g of vancomycin was placed in the wound. Fascia was closed with #1 and 0 Vicryl suture, #2 strata fix. Subcutaneous layer was closed with 2 0 Vicryl. Skin was closed with staples. Sterile dressing was applied. Patient was placed on a stretcher and woken from anesthesia. Patient was taken to PACU in stable condition. Postoperative patient was found to be neuro intact in the PACU.
Preoperative diagnosis: lumbar stenosis L2-3, L3-4, L4-5, grade 1 spondylolisthesis L4-5, recurrent lumbar stenosis L4-5, degenerative disc disease, facet arthropathy, degenerative scoliosis
Postop diagnosis: same
Procedure: L2-3 lumbar laminectomy, L3-4 lumbar laminectomy, L4-5 revision lumbar laminectomy, L2-5 posterior instrumented fusion, L2-5 posteriolateral mass fusion with allograft, harvesting of bone graft from same incision, use of navigation and Stealth
BACKGROUND: Patient with lower back pain and pain radiating down lower extremity. Patient has failed all conservative treatment modalities. Risks and benefits of the surgical procedure was discussed with the patient. Risks including but not limited to infection, blood loss, damage to blood vessels and nerve roots, need for more surgery, dural tear, PE, stroke, DVT, adjacent segment disease, revision surgery, death were discussed with the patient. Patient elected to proceed with the procedure
OPERATIVE FINDINGS: Severe lumbar stenosis L2-3, L3-4, recurrent lumbar stenosis L4-5 with severe scar tissue, facet arthropathy, grade 1 degenerative spondylolisthesis L4-5, obesity
OPERATIVE PROCEDURE:
The patient was placed on the operating table in the prone position on the Jackson table after induction of general anesthesia. X-ray was used to identify the lumbar L2-5 level. Lumbar spine was prepped and draped in sterile fashion. Standard time-out was called. Patient's operative site was confirmed by everyone. Midline incision was made. Dissection was carried throughout the subcutaneous layer and lumbar dorsal fascia was identified. Fascia was incised bilateral to the spinous process. Dissection was carried all the way down to the lamina and lamina of L L2-5 were dissected and identified. Facet joints were identified. Patient had a previous lumbar laminectomy at L4-5. We noticed that there was a lot of scar tissue around the previous laminectomy site on the right side. More than normal amount of procedure services were required to carefully dissect as not to injure the dural sac and to identify the previous lamina. We had to be extremely careful to identify the previous lamina and the facet joints due to previous scar tissue and laminectomy as well as due to patient's obesity. We were careful to make sure that the L1-2 joint capsule was not disrupted. We noticed that there was severe amount of facet arthropathy at L3-4, L4-5. We then proceeded with placement of pedicle screws. Stealth navigation was brought in. The clamp was placed on L5 spinous process. We then brought in the O-arm and did an intraoperative CT scan. Navigated gearshift was used to make a hole in the vertebral body. Patient had degenerative scoliosis which made the orientation of the pedicles extremely difficult along with previous scar tissue. The pedicle holes were then tapped with 5.5 mm tap and 6.5 mm x 50 mm screws were placed in the L2, L3, L4 pedicles. We placed 6.5 mm x 40 mm pedicle screws in the L5 pedicles bilaterally. We had excellent bite of the pedicle screws. AP and lateral x-rays were done which showed adequate positioning of the hardware. Neuromonitoring was used. The screws were checked with threshold above 20. Due to previous scar tissue and patient's BMI of more than 33 which necessitated increased amount of work for placement of the screws as well. We then proceeded with the decompression. Midline interspinous ligaments between L3-4, L4-5 spinous processes were rongeured. We then placed a lamina spreader to distract the L3-4 lamina. I proceeded with decompression of the lateral recess bilaterally. The curette was used to undermine the superior articular facet of L4 bilaterally. I used a Kerrison rongeur to decompress the lateral recess and the foramina by doing a partial facetectomy of the superior articular facets the L4 bilaterally. I used an osteotome to do a complete facetectomy of inferior L3 facets bilaterally to help us with the correction of the deformity as well as to help decompress the lateral recesses bilaterally as well as the laminas bilaterally. After we had adequate decompression of the lateral recess, with proceed with a complete laminectomy of L3 bilaterally. Complete laminectomy including the midline spinous process was removed using Kerrison rongeur's, bur. Patient had severe ligamentum hypertrophy which was causing the dural sac to curve due to osteophytes pushing on the sac. We carefully removed all of the osteophytes and spurs causing the curvature of the dural sac.. I used Kerrison rongeurs to remove the ligamentum hypertrophy and to fully decompress the dural sac. Woodson, nerve hook was used to confirm adequate decompression bilaterally. We noticed that the lateral recesses, foramens were adequately decompressed. I then turned our attention to decompression at L4-5 level. This took more than normal amount of procedural services due to patient having a previous laminectomy on the right side at L4. MRI showed severe stenosis bilaterally. We carefully identified the previous laminectomy site and used a Kerrison rongeur, Leksell rongeur to remove the midline spinous process. I used a curette to undermine the lamina and to separate the dural scar tissue from the undersurface of the lamina. Then used a Kerrison to do a complete laminectomy bilaterally. Patient had significant lateral recess stenosis from overgrowth of the superior articular facets of L5 bilaterally. I used #2 and #3 Kerrisons to remove the medial and the superior aspect of the L5 facets bilaterally to decompress the lateral recess as well as the neural foramens. Patient a lot of scar tissue on the right side against the dural sac. We had to carefully elevate the scar tissue from the dural sac to fully decompress the lateral recess. I felt we had adequate decompression at L4-5 level as well. We then proceeded to decompress the L2-3 level. I then did a laminectomy on the left side L2-3 level. I used the bur and Kerrison to do laminectomy of the left side L2 lamina. I was then able to undermine the ligamentum from the lamina and to decompress the midline as well as the right side of the undersurface of the lamina at L2 as well. Patient had moderate stenosis at that level. We felt we had adequate decompression and L2-3 level as well just using a unilateral laminectomy. The nerve roots were identified and were found to be free. The exiting and traversing nerve root were confirmed to be free using nerve hook. The navigated clamp was then removed from the L5 spinous process.
We then proceeded to obtain adequate hemostasis with Floseal, bipolar. We proceeded with the placement of 2 rods bilaterally. end caps were tightened. AP and lateral x-rays were done which showed adequate positioning of the hardware as well as improvement of the scoliotic curve. Transverse processes were then decorticated along with the facets. Allograft mixed with autograft bone graft was placed in the posterolateral gutters and around the facets and transverse processes for posterolateral fusion. Floseal was used to obtain adequate hemostasis. Wound was then thoroughly irrigated with Irrisept and saline solution. 2 medium Hemovac drain was placed.
1 g of vancomycin was placed in the wound. Fascia was closed with #1 and 0 Vicryl suture, #2 strata fix. Subcutaneous layer was closed with 2 0 Vicryl. Skin was closed with staples. Sterile dressing was applied. Patient was placed on a stretcher and woken from anesthesia. Patient was taken to PACU in stable condition. Postoperative patient was found to be neuro intact in the PACU.