sdunaway1
Guru
I feel that we should code this surgery as:
22600 ( C2)
22610 -51-59 (T1)
22614*5 (C3-C7 & T2)
22852 -ALL OF THE LEVELS ARE EITHER OVERLAPPING WITH EXPLORATION OR ADDING NEW INSTRUMENTATION- THE ONLY LEVELS ARE T5,6 W NO SCREWS REMOVED BUT THERE IS EXPLORATION AT THESE LEVELS
22830 (T2-76)
22842 (C2-T2)
38220-51-59
20930
20936
76001-26-51-59
Can someone please check and give their opinion? This case was done in Trauma and it is very difficult! I was also wondering about 22849 at level T2 & T2 because those levels have been removed and reinserted.
PREOPERATIVE DIAGNOSIS:
1. Multiple cervical spinal fractures including C3, C4, C5 and a compression fracture of C7
with significant ligamentous instability.
2. Acute spinal cord injury with paraplegia.
POSTOPERATIVE DIAGNOSIS:
1. Multiple cervical spinal fractures including C3, C4, C5 and a compression fracture of C7
with significant ligamentous instability.
2. Acute spinal cord injury with paraplegia.
3. Facet instability C3-C4, C4-C5, and to a lesser extent C5-C6 level.
OPERATION PERFORMED:
1. Exploration of prior T2-T6 fusion, incision and explantation of instrumentation
posterior cervical and thoracic instrumentation from prior C6-T6 posterior fusion. Removing
the Synthes Synapse system from C6 and then the USS system from Synthes T1-T2, T5 and T6 as
well as the connecting rods bilaterally.
2. Posterior fusion from C2 down through T2 using the Quartex system from Globus Medical
with pars interarticularis screws in C2, lateral mass screws C3, C4, C5, and C6 and then
pedicle screws T1 and T2 bilaterally.
3. Bony fusion with morselized cancellous autograft, allograft and Vitoss sponges with bone
marrow aspiration.
4. Exparel 20 mL diluted up to 60 mL with sterile normal saline injected into the
subcutaneous tissues bilaterally along the cervical spine portion of the incision.
ANESTHESIA: General.
PREOPERATIVE MEDICATION: Vancomycin 1 gram IV at induction. Tranexamic acid 10 mg/kg given
at the time of incision to decrease intraoperative blood loss.
PREOPERATIVE SUMMARY: The patient is a 24-year-old white male who is status post a spinal
cord injury with a burst fracture of T3 and compression fracture of T4 2 years ago. He was
treated at Harborview Medical Center by Dr. Bellabarba who did a C6-T6 posterior fusion.
Postoperatively, the patient was paraplegic with neurological level of T2. The patient was
able to get around independently in a wheelchair since that time, but 2 nights ago, the
night before last, on 11/02/2017, was involved in a rollover vehicle accident. He was in a
truck that rolled over because of bad whether and sustained multiple fractures of his
cervical spine above his prior fusion. Cervical spine CT scan showed left-sided C3 lateral
mass fracture, left-sided C4 fracture, both in the vertebral body and posteriorly in the
lamina and anterior inferior C4 vertebral body, right C4 and C5 laminar fractures and a
compression fracture of C7 with loss of approximately 50% vertebral body height. No
evidence of any retropulsed bone seen.
An MRI scan of the cervical spine was carried out the following morning which showed spinal
cord edema from the top of C3 down to the bottom of C5 but no evidence of hematoma within
the spinal cord. Also showed significant edema of the soft tissues of the posterior
cervical spine as well as probable facet instability C3-C4 and C4-C5 bilaterally. The
patient had significantly increased weakness of the upper extremities compared to preop
affecting the left upper extremity more than the right upper extremity. Based on all this,
I did recommend surgery, namely an exploration, removal of the patient's prior
instrumentation from C6 down to T6 followed by a fusion from C2 to at least T2 and possibly
all the way down to T6 depending on the strength of his prior fusion. I did discuss this
with the family. I did explain the rationale for the surgery, including potential benefits
and risks including potential risks of CSF leak, postoperative wound hematoma, possibility
of increased pain, weakness and sensation loss in the upper extremities. He is already
insensate and has no motor function below T2, the possibility of failure of the fusion
requiring revision in the future, the possibility of infection and the risks of general
anesthesia including the possibility of death. Mr. Simon understood these risks and he did
consent to surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room on his ICU bed
where he underwent successful induction of general anesthesia and placement of an
endotracheal tube. Correct placement of the ET tube was checked by Anesthesia and when it
was confirmed to be in the correct position, the airway was secured. The patient was then
maneuvered into a prone position on a Wilson laminectomy frame and his head was placed in
Mayfield head fixation to keep the neck in neutral position. I did supervise the
intubation. The neck was kept in neutral position throughout the intubation process.
Once the patient was positioned in a prone position in Mayfield head fixation, the arms were
taped back to improve radiographic imaging of the cervical spine and all pressure points
were carefully checked and padded.
The posterior portion of the patient's neck was shaved and then the patient was prepped from
the inion all the way along his posterior neck, posterior thoracic spine to the bottom of
his prior thoracic incision. I should mention the back of the patient's skin was washed
with chlorhexidine gluconate and then rinsed off and then removed and then dried. Following
this, the skin was prepped in the usual fashion with the posterior portion of the incision
planned from C2 all the way down to T6 was draped off in the usual fashion.
At this time, a timeout was performed in the operating room where the case to be performed
was discussed including potential complications. We checked to make sure all the equipment
ready and available to perform the surgery. We did the usual preoperative checklist.
The patient's prior incision was opened up from C6 down to T6. This was
carried down sharply to the thoracic fascia and then dissection was carried laterally to
expose the heads of the screws in C6, T1, T2 and T5 and T6 exposing the entire rod which was
a tapered rod 1/4-inch from C2 down to T2 down to T6 and then tapered down to 3.5 diameter
rod at C6. This is prefabricated tapered rod that was used bilaterally. The dissection
over this instrumentation was tedious but it was able to be completely exposed and then
disarticulated and all the instrumentation was removed. From C,6 lateral masses were
removed, a 4.0 x 14 mm screw. There was no instrumentation in C7. At T1, there were 5 mm x
30 mm pedicle screws placed. At T2, 5 mm x 35 mm screws bilaterally and then bilaterally at
T5 and T6, they were 5.0 x 40 mm screws. All the screw holes in the bone were packed with
Gelfoam and a small amount of FloSeal to control bleeding. The fusion from T1 to T6 was showed a solid bony
fusion.
At this time, an incision was then extended up to C2 in the midline, carried down and
subperiosteal dissection was carried out along the lateral aspect of the spinous processes
of C2, C3, C4, C5, C6, and C7 bilaterally exposing the bilateral lamina as well as the
lateral masses at each of these levels. Self-retaining retractors were then placed to hold
the exposure. As expected, there was facet incompetence at C3-C4 and C4-C5 bilaterally, to
a lesser extent at the C5-C6 level.
At this time, the individual facet joints bilaterally at C3-C4, C4-C5, C5-C6 and C6-C7 were
destroyed removing the posterior capsular ligaments and then removing the articular
cartilage at each facet level all the way down to bone to allow bony fusion to occur. This
was then lightly drilled with the Midas Rex dissecting tool using an AM-8 attachment to
create good bleeding bone perfusion. Into this was packed morselized cancellous autograft
and allograft bone into the facets bilaterally to achieve interfacet bony fusion.
At this point, the instrumentation was placed from C2 down to T2. I initially placed
pedicle screws in T1 and T2 through the prior holes. In this case, I used 5.0 x 30 mm
screws in T1, 5.0 x 35 mm screws in T2 with good purchase obtained in all 4 of these screws,
again using the Quartex system from Globus Medical. The next screws were placed in the pars
interarticularis of C2 bilaterally. Screws were placed under fluoroscopic guidance and I
placed 3.5 x 24 mm screws bilaterally in the pars interarticularis of C2 bilaterally with
good purchase obtained bilaterally. In C3, C4, C5, and C6, I placed lateral mass screws in
the usual fashion angling the screws superiorly and laterally toward the upper outer
quadrant of each lateral mass with good purchase. The left C3 lateral mass was noted to be
fractured and so the purchase in this lateral mass was not as good as in all of the other
locations. In all cases, I placed 4.0 x 14 mm screws, all placed under direct anatomic
guidance with good holding purchase obtained in all locations except the left C3 lateral
mass as mentioned above.
Following this, a connecting rod was used to connect up all the screw heads from C2 down to
T2. I used a 4 mm diameter rod cut to 130 mm in length and then bent to recapitulate some
of the patient's cervical lordosis and the upper portion of the patient's thoracic kyphosis.
The rods were fitted into each of the tulips, each of the heads of the screws and then
tightened down sequentially, all placed under a small amount of compression to improve the
overall strength of the construct. Once they were connected, the construct was quite solid.
There was significant instability of the cervical spine as a result of the patient's
fractures and after the instrumentation was connected up, there was a solid construct from
C2 down to T2 and all the way down to T6 because the prior fusion was solid. I did place 2
crosslinks, 1 between the C3 and C4 levels of the lateral mass screws and then another 1
placed between C6 and C7. These were tightened down to the appropriate torque to improve
the overall strength of the construct.
Following this, the dorsal aspect of the lamina of C2, C3, C4, C5, C6, and C7 were all
decorticated as well as the lateral aspect of the lateral masses. Bone marrow was collected
from the holes drilled in the lateral masses and this was mixed with Vitoss which was then
placed over the lamina both medial and lateral to the screws, and then over this was packed
morselized cancellous autograft from the spinous processes of the cervical spine from C3
down to C7 and also morselized cancellous allograft bone. Final lateral fluoroscopy showed
the pars interarticularis screws, the lateral mass screws and the pedicle screws all
properly placed respectively in the spinous as noted in the body of this dictation above.
Two Hemovac drains were placed in the supralaminar space, brought out through separate stab
wound incisions inferior and lateral to the incision and sutured at their exit point to
prevent premature removal and then attached to bulb suction. The incision was then closed
in layers in usual fashion with the skin being closed with interrupted vertical mattress
sutures using monofilament nylon suture for increased strength because of this high tension
area of his skin overlying the cervical and upper thoracic spine. Exparel 20 mls, diluted up to
60 mls injected into the subcutaneous tissues to mitigate post-op incisional pain. The incision was then
dressed with bacitracin ointment, Telfa, sterile 4 x 4's which were taped to the patient's
back.
I should mention that the incision was irrigated once the retractors were placed with
Irrisept solution, which is a dilute solution of chlorhexidine gluconate, to help sterilize
the wound and this was done again at the end of the procedure just before closure and then
the final irrigation was with bacitracin normal saline solution.
Following this, the patient was then maneuvered back into supine position and was still
determining whether to extubate or to leave intubated to be taken back to the intensive care
unit. The patient tolerated the procedure well and left the operating room in stable
condition. Patient was moving both upper extremities with same preop weakness.
This procedure was done with the aid of my physician assistant, Magen Schmidt, PA-C, who was
invaluable in maintaining retraction, suctioning and otherwise assisting in the operation to
make it safer and more efficacious for the patient.
ESTIMATED BLOOD LOSS FOR THE PROCEDURE: 200 mL.
COMPLICATIONS: None.
SPECIMEN SENT TO PATHOLOGY: None.
THANK YOU SO MUCH FOR YOUR HELP!!!!!!!!!
22600 ( C2)
22610 -51-59 (T1)
22614*5 (C3-C7 & T2)
22852 -ALL OF THE LEVELS ARE EITHER OVERLAPPING WITH EXPLORATION OR ADDING NEW INSTRUMENTATION- THE ONLY LEVELS ARE T5,6 W NO SCREWS REMOVED BUT THERE IS EXPLORATION AT THESE LEVELS
22830 (T2-76)
22842 (C2-T2)
38220-51-59
20930
20936
76001-26-51-59
Can someone please check and give their opinion? This case was done in Trauma and it is very difficult! I was also wondering about 22849 at level T2 & T2 because those levels have been removed and reinserted.
PREOPERATIVE DIAGNOSIS:
1. Multiple cervical spinal fractures including C3, C4, C5 and a compression fracture of C7
with significant ligamentous instability.
2. Acute spinal cord injury with paraplegia.
POSTOPERATIVE DIAGNOSIS:
1. Multiple cervical spinal fractures including C3, C4, C5 and a compression fracture of C7
with significant ligamentous instability.
2. Acute spinal cord injury with paraplegia.
3. Facet instability C3-C4, C4-C5, and to a lesser extent C5-C6 level.
OPERATION PERFORMED:
1. Exploration of prior T2-T6 fusion, incision and explantation of instrumentation
posterior cervical and thoracic instrumentation from prior C6-T6 posterior fusion. Removing
the Synthes Synapse system from C6 and then the USS system from Synthes T1-T2, T5 and T6 as
well as the connecting rods bilaterally.
2. Posterior fusion from C2 down through T2 using the Quartex system from Globus Medical
with pars interarticularis screws in C2, lateral mass screws C3, C4, C5, and C6 and then
pedicle screws T1 and T2 bilaterally.
3. Bony fusion with morselized cancellous autograft, allograft and Vitoss sponges with bone
marrow aspiration.
4. Exparel 20 mL diluted up to 60 mL with sterile normal saline injected into the
subcutaneous tissues bilaterally along the cervical spine portion of the incision.
ANESTHESIA: General.
PREOPERATIVE MEDICATION: Vancomycin 1 gram IV at induction. Tranexamic acid 10 mg/kg given
at the time of incision to decrease intraoperative blood loss.
PREOPERATIVE SUMMARY: The patient is a 24-year-old white male who is status post a spinal
cord injury with a burst fracture of T3 and compression fracture of T4 2 years ago. He was
treated at Harborview Medical Center by Dr. Bellabarba who did a C6-T6 posterior fusion.
Postoperatively, the patient was paraplegic with neurological level of T2. The patient was
able to get around independently in a wheelchair since that time, but 2 nights ago, the
night before last, on 11/02/2017, was involved in a rollover vehicle accident. He was in a
truck that rolled over because of bad whether and sustained multiple fractures of his
cervical spine above his prior fusion. Cervical spine CT scan showed left-sided C3 lateral
mass fracture, left-sided C4 fracture, both in the vertebral body and posteriorly in the
lamina and anterior inferior C4 vertebral body, right C4 and C5 laminar fractures and a
compression fracture of C7 with loss of approximately 50% vertebral body height. No
evidence of any retropulsed bone seen.
An MRI scan of the cervical spine was carried out the following morning which showed spinal
cord edema from the top of C3 down to the bottom of C5 but no evidence of hematoma within
the spinal cord. Also showed significant edema of the soft tissues of the posterior
cervical spine as well as probable facet instability C3-C4 and C4-C5 bilaterally. The
patient had significantly increased weakness of the upper extremities compared to preop
affecting the left upper extremity more than the right upper extremity. Based on all this,
I did recommend surgery, namely an exploration, removal of the patient's prior
instrumentation from C6 down to T6 followed by a fusion from C2 to at least T2 and possibly
all the way down to T6 depending on the strength of his prior fusion. I did discuss this
with the family. I did explain the rationale for the surgery, including potential benefits
and risks including potential risks of CSF leak, postoperative wound hematoma, possibility
of increased pain, weakness and sensation loss in the upper extremities. He is already
insensate and has no motor function below T2, the possibility of failure of the fusion
requiring revision in the future, the possibility of infection and the risks of general
anesthesia including the possibility of death. Mr. Simon understood these risks and he did
consent to surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room on his ICU bed
where he underwent successful induction of general anesthesia and placement of an
endotracheal tube. Correct placement of the ET tube was checked by Anesthesia and when it
was confirmed to be in the correct position, the airway was secured. The patient was then
maneuvered into a prone position on a Wilson laminectomy frame and his head was placed in
Mayfield head fixation to keep the neck in neutral position. I did supervise the
intubation. The neck was kept in neutral position throughout the intubation process.
Once the patient was positioned in a prone position in Mayfield head fixation, the arms were
taped back to improve radiographic imaging of the cervical spine and all pressure points
were carefully checked and padded.
The posterior portion of the patient's neck was shaved and then the patient was prepped from
the inion all the way along his posterior neck, posterior thoracic spine to the bottom of
his prior thoracic incision. I should mention the back of the patient's skin was washed
with chlorhexidine gluconate and then rinsed off and then removed and then dried. Following
this, the skin was prepped in the usual fashion with the posterior portion of the incision
planned from C2 all the way down to T6 was draped off in the usual fashion.
At this time, a timeout was performed in the operating room where the case to be performed
was discussed including potential complications. We checked to make sure all the equipment
ready and available to perform the surgery. We did the usual preoperative checklist.
The patient's prior incision was opened up from C6 down to T6. This was
carried down sharply to the thoracic fascia and then dissection was carried laterally to
expose the heads of the screws in C6, T1, T2 and T5 and T6 exposing the entire rod which was
a tapered rod 1/4-inch from C2 down to T2 down to T6 and then tapered down to 3.5 diameter
rod at C6. This is prefabricated tapered rod that was used bilaterally. The dissection
over this instrumentation was tedious but it was able to be completely exposed and then
disarticulated and all the instrumentation was removed. From C,6 lateral masses were
removed, a 4.0 x 14 mm screw. There was no instrumentation in C7. At T1, there were 5 mm x
30 mm pedicle screws placed. At T2, 5 mm x 35 mm screws bilaterally and then bilaterally at
T5 and T6, they were 5.0 x 40 mm screws. All the screw holes in the bone were packed with
Gelfoam and a small amount of FloSeal to control bleeding. The fusion from T1 to T6 was showed a solid bony
fusion.
At this time, an incision was then extended up to C2 in the midline, carried down and
subperiosteal dissection was carried out along the lateral aspect of the spinous processes
of C2, C3, C4, C5, C6, and C7 bilaterally exposing the bilateral lamina as well as the
lateral masses at each of these levels. Self-retaining retractors were then placed to hold
the exposure. As expected, there was facet incompetence at C3-C4 and C4-C5 bilaterally, to
a lesser extent at the C5-C6 level.
At this time, the individual facet joints bilaterally at C3-C4, C4-C5, C5-C6 and C6-C7 were
destroyed removing the posterior capsular ligaments and then removing the articular
cartilage at each facet level all the way down to bone to allow bony fusion to occur. This
was then lightly drilled with the Midas Rex dissecting tool using an AM-8 attachment to
create good bleeding bone perfusion. Into this was packed morselized cancellous autograft
and allograft bone into the facets bilaterally to achieve interfacet bony fusion.
At this point, the instrumentation was placed from C2 down to T2. I initially placed
pedicle screws in T1 and T2 through the prior holes. In this case, I used 5.0 x 30 mm
screws in T1, 5.0 x 35 mm screws in T2 with good purchase obtained in all 4 of these screws,
again using the Quartex system from Globus Medical. The next screws were placed in the pars
interarticularis of C2 bilaterally. Screws were placed under fluoroscopic guidance and I
placed 3.5 x 24 mm screws bilaterally in the pars interarticularis of C2 bilaterally with
good purchase obtained bilaterally. In C3, C4, C5, and C6, I placed lateral mass screws in
the usual fashion angling the screws superiorly and laterally toward the upper outer
quadrant of each lateral mass with good purchase. The left C3 lateral mass was noted to be
fractured and so the purchase in this lateral mass was not as good as in all of the other
locations. In all cases, I placed 4.0 x 14 mm screws, all placed under direct anatomic
guidance with good holding purchase obtained in all locations except the left C3 lateral
mass as mentioned above.
Following this, a connecting rod was used to connect up all the screw heads from C2 down to
T2. I used a 4 mm diameter rod cut to 130 mm in length and then bent to recapitulate some
of the patient's cervical lordosis and the upper portion of the patient's thoracic kyphosis.
The rods were fitted into each of the tulips, each of the heads of the screws and then
tightened down sequentially, all placed under a small amount of compression to improve the
overall strength of the construct. Once they were connected, the construct was quite solid.
There was significant instability of the cervical spine as a result of the patient's
fractures and after the instrumentation was connected up, there was a solid construct from
C2 down to T2 and all the way down to T6 because the prior fusion was solid. I did place 2
crosslinks, 1 between the C3 and C4 levels of the lateral mass screws and then another 1
placed between C6 and C7. These were tightened down to the appropriate torque to improve
the overall strength of the construct.
Following this, the dorsal aspect of the lamina of C2, C3, C4, C5, C6, and C7 were all
decorticated as well as the lateral aspect of the lateral masses. Bone marrow was collected
from the holes drilled in the lateral masses and this was mixed with Vitoss which was then
placed over the lamina both medial and lateral to the screws, and then over this was packed
morselized cancellous autograft from the spinous processes of the cervical spine from C3
down to C7 and also morselized cancellous allograft bone. Final lateral fluoroscopy showed
the pars interarticularis screws, the lateral mass screws and the pedicle screws all
properly placed respectively in the spinous as noted in the body of this dictation above.
Two Hemovac drains were placed in the supralaminar space, brought out through separate stab
wound incisions inferior and lateral to the incision and sutured at their exit point to
prevent premature removal and then attached to bulb suction. The incision was then closed
in layers in usual fashion with the skin being closed with interrupted vertical mattress
sutures using monofilament nylon suture for increased strength because of this high tension
area of his skin overlying the cervical and upper thoracic spine. Exparel 20 mls, diluted up to
60 mls injected into the subcutaneous tissues to mitigate post-op incisional pain. The incision was then
dressed with bacitracin ointment, Telfa, sterile 4 x 4's which were taped to the patient's
back.
I should mention that the incision was irrigated once the retractors were placed with
Irrisept solution, which is a dilute solution of chlorhexidine gluconate, to help sterilize
the wound and this was done again at the end of the procedure just before closure and then
the final irrigation was with bacitracin normal saline solution.
Following this, the patient was then maneuvered back into supine position and was still
determining whether to extubate or to leave intubated to be taken back to the intensive care
unit. The patient tolerated the procedure well and left the operating room in stable
condition. Patient was moving both upper extremities with same preop weakness.
This procedure was done with the aid of my physician assistant, Magen Schmidt, PA-C, who was
invaluable in maintaining retraction, suctioning and otherwise assisting in the operation to
make it safer and more efficacious for the patient.
ESTIMATED BLOOD LOSS FOR THE PROCEDURE: 200 mL.
COMPLICATIONS: None.
SPECIMEN SENT TO PATHOLOGY: None.
THANK YOU SO MUCH FOR YOUR HELP!!!!!!!!!