Spine coding help

EMS7775

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Lithonia, GA
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PREOPERATIVE DIAGNOSIS:Cervical myelopathy.

POSTOPERATIVE DIAGNOSIS: Cervical myelopathy.

OPERATION/PROCEDURES PERFORMED:
1. Third cervical vertebral dome laminectomy.
2. Fourth cervical vertebra-to-sixth cervical vertebra laminoplasty.







INDICATIONS FOR PROCEDURE: The patient is a 52-year-old gentleman who
has been followed by us in the spine clinic for his myelopathic
symptoms. He presents with positive physical signs of cervical
myelopathy including clumsiness, ataxic gait, pain radiating down
bilateral arms, as well as weakness of his intrinsics, biceps, deltoids,
extensors flexors. Also complicating this situation is that he was
also diagnosed with bilateral cubital tunnel syndrome which aggravates
his bilateral upper extremities as well below the level of his elbow.
After extensive discussion about his dual pathology of his myelopathy
and bilateral cubital tunnel syndrome, the patient elected to take care
of his myelopathic issues first since nonoperative management had
failed. He elected to undergo a C3 dome laminectomy and C4-C6
laminoplasty. All his questions were answered. The procedure was
explained in detail so as that the patient could understand. The
patient signed consent for the procedure, as well as blood transfusion
as necessary.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating
room in stable condition and was induced with general endotracheal
intubation by the anesthesia team without any complications.
Subsequently, a Foley catheter was placed, a Mayfield head frame was
placed on his head, and the patient was positioned in the standard
prone position with his arms tucked and Mayfield frame attached to the
bed. He was stable throughout this entire positioning, and the patient
was prepped in the universal sterile precaution method in his posterior
cervical region for operative site; 0.25% Marcaine with epinephrine was
injected into the incision site before the incision was made. The
incision was brought down from skin down to his cervical spinous
processes from C3 to C7, and soft tissue was dissected of lamina out to
the medial edge of the lateral processes from C3 down to C6. All
bleeding was controlled by coagulation using Bovie, and the level of
cervical spines were confirmed using lateral cross-table x-ray
revealing marker on the C3 spinous process. Next, a dome laminectomy
of C3 was performed using initially rongeur, taking part of the C3
spinous process off down to the lamina and then using a diamond bur to
bur down a quarter of the height of the lamina. Subsequently, the
canal was opened using Kerrisons, and the ligamentum flavum was excised
out. Then, the spinous interspace between C6 and C7 was rongeured out,
and the ligamentum flavum was excised as well. The superior aspect of
C7 lamina was undercut using Kerrisons allowing for breathing room for
the spinal cord at that level. Once the C3 dome laminectomy and the
interspinous process between C6 and C7 were prepared, the left side of
C4, C5, and C6 were burred at the lateral edge of the lamina using a
diamond bur all the way through the lamina, and the ligamentum flavum
was cleared using a curved curette. All bleeding was controlled by
coagulation using the bipolar. Once the left side had been burred all
the way through, we paid attention to the right side of the lateral
aspect of the lamina, which was burred through the cortex and
cancellous bone leaving intact inferior cortex C4 on the right, C5 on
the right, and C6 on the right. A greenstick fracture was created at
this junction site on the right, and an open-door laminoplasty was
created levering up on the open left side of C4, C5, and C6, and
hinging on the right C4, C5, and C6. The underside of the lamina was
cleared of all adhesions using a Woodson, and the spinal cord was
visualized directly and cleared of any adhesions or compressions.
Next, we used the Medtronic laminoplasty plate system, and 12-mm strut
plates were used at C6, then C5 and C4. Three screws were used at each
plate to secure the strut plate down to the lateral process and to the
lamina of the open laminoplasty. Once again, we visually inspected
using the Woodson the space available for the cord after the
laminoplasty was completed, and any bleeding was controlled using the
bipolar coagulation. A Hemovac was placed to evacuate any collection
of drainage, and the deep layers were closed with 0 Vicryl, as well as
the fascia. Then, 2-0 Vicryls were used to close the subdermal region,
and Monocryl was used to close the skin in a plastic surgery manner.
Subsequently, a closing confirmatory lateral x-ray was taken to make
sure that we were completed at the correct levels, and no
instrumentations were retained within the wound. The wound was dressed
in Dermabond, 4 x 4 sterile gauze, and tape. The patient was stable
throughout the entire procedure and was extubated without
complications.

Would this be coded as 63051 not sure??
 
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