Alfaro33
Networker
Our team is disagreeing on the coding for this procedure. Specifically if the arthrodesis should be coded. Some feel the documentation is insufficient.
Thoughts?
Pre-op Diagnosis
Severe cervical spondylosis with myelopathy
Post-op Diagnosis
Severe cervical spondylosis with myelopathy
Operation
1. C5 anterior cervical corpectomy greater than 75%.
2. Through separate incision, harvesting of iliac crest graft.
3. Insertion of iliac crest strut graft between C4-C6.
4. Anterior plating C4-6.
5. Use of intraoperative microscope
Anesthesia
General endotracheal
Findings
Anterior plating with anatomic alignment
Procedure in detail:
Patient was brought to the operative theater intubated anesthetized supine position shoulder bump was placed transversely across the shoulder blades he was then prepped and draped in normal sterile fashion preoperative antibiotics were given time-out was accomplished we used 1 of the natural neck fold on the right side of the neck to infiltrate with 7 cc lidocaine with epinephrine. Also over the iliac crest we infiltrated with 10 cc of lidocaine with epinephrine we undertook subperiosteal dissection of the portion of the iliac crest. We then used the oscillating saw to fashion a graft some 25 mm in length. This area was then copiously irrigated with warm saline bone wax was placed over the graft site. We then closed the subcutaneous tissue with interrupted 2 0 Vicryl the skin was closed running 4 Monocryl in a thin layer of Dermabond was placed on top. We made our transverse incision on the right side of the neck undermined the skin in all directions. And found the platysmas muscle. This was sectioned sharply in a transverse fashion. We then found the anterior border sternocleidomastoid muscle and followed in avascular plane down the prevertebral fascia. We then dissected out the inferior portion of C4 down to the superior portion of C6. This was confirmed with a bayoneted spinal needle and C-arm fluoroscopy which was sterilely draped into the field. We undermined the lips longus colli muscles and reflected them laterally. We then placed a retractor under the lips longus colli muscles. Satisfied with this we then placed Caspar pins at C4 and C6 respectively. Three clicks of distraction were placed on the Caspar pins. We then brought in the high-powered microscope the rest case carried forth under microscopic observation excluding the skin closure. We then used the high-speed drill to accomplished our corpectomy. We drilled this bone out laterally as well as inferiorly to the C4-5 and C5-6 disc. We drilled away posteriorly to we reached the posterior longitudinal ligament. This was removed in piecemeal with a series of Kerrison Rogers. We then undercut C4 and C6 with a series of Kerrison Rogers. We accomplished widely decompressive foraminotomies bilaterally at C4-5 and C5-6. We then palpated the Woodson the nerve roots were noted be free and clear. Satisfied with this we then fashioned the iliac crest graft prepared the endplates of C4 and C6 respectively the bone graft was tamped into place. We then removed distraction on the Caspar pins. Satisfied with x-ray we then removed the Caspar pins and used bone wax for the holes. . We then used a Stryker Ozark view plate and placed 16 mm screws at C4 and C6 respectively under C-arm fluoroscopy. We placed a 12 mm screw into the graft in the center of the plate. Satisfied position we then final tightened the plate at all 3 sites. We then copiously irrigated with warm saline. We removed self-retaining retractor went back in with handheld Cloward any extraneous bleeding was controlled bipolar cautery. We then took final AP and lateral x-rays satisfied with this we then closed the platysmas muscle with interrupted 3-0 Vicryl the skin was closed running 4 Monocryl in a thin layer Dermabond placed on top. Patient tolerated procedure well without complication estimated blood loss was 100 mL IV fluids 1200 mL crystalloid. Patient was subsequently awakened extubated taken to PACU in good condition he will be off to med surge floor once satisfied PACU criteria
Thoughts?
Pre-op Diagnosis
Severe cervical spondylosis with myelopathy
Post-op Diagnosis
Severe cervical spondylosis with myelopathy
Operation
1. C5 anterior cervical corpectomy greater than 75%.
2. Through separate incision, harvesting of iliac crest graft.
3. Insertion of iliac crest strut graft between C4-C6.
4. Anterior plating C4-6.
5. Use of intraoperative microscope
Anesthesia
General endotracheal
Findings
Anterior plating with anatomic alignment
Procedure in detail:
Patient was brought to the operative theater intubated anesthetized supine position shoulder bump was placed transversely across the shoulder blades he was then prepped and draped in normal sterile fashion preoperative antibiotics were given time-out was accomplished we used 1 of the natural neck fold on the right side of the neck to infiltrate with 7 cc lidocaine with epinephrine. Also over the iliac crest we infiltrated with 10 cc of lidocaine with epinephrine we undertook subperiosteal dissection of the portion of the iliac crest. We then used the oscillating saw to fashion a graft some 25 mm in length. This area was then copiously irrigated with warm saline bone wax was placed over the graft site. We then closed the subcutaneous tissue with interrupted 2 0 Vicryl the skin was closed running 4 Monocryl in a thin layer of Dermabond was placed on top. We made our transverse incision on the right side of the neck undermined the skin in all directions. And found the platysmas muscle. This was sectioned sharply in a transverse fashion. We then found the anterior border sternocleidomastoid muscle and followed in avascular plane down the prevertebral fascia. We then dissected out the inferior portion of C4 down to the superior portion of C6. This was confirmed with a bayoneted spinal needle and C-arm fluoroscopy which was sterilely draped into the field. We undermined the lips longus colli muscles and reflected them laterally. We then placed a retractor under the lips longus colli muscles. Satisfied with this we then placed Caspar pins at C4 and C6 respectively. Three clicks of distraction were placed on the Caspar pins. We then brought in the high-powered microscope the rest case carried forth under microscopic observation excluding the skin closure. We then used the high-speed drill to accomplished our corpectomy. We drilled this bone out laterally as well as inferiorly to the C4-5 and C5-6 disc. We drilled away posteriorly to we reached the posterior longitudinal ligament. This was removed in piecemeal with a series of Kerrison Rogers. We then undercut C4 and C6 with a series of Kerrison Rogers. We accomplished widely decompressive foraminotomies bilaterally at C4-5 and C5-6. We then palpated the Woodson the nerve roots were noted be free and clear. Satisfied with this we then fashioned the iliac crest graft prepared the endplates of C4 and C6 respectively the bone graft was tamped into place. We then removed distraction on the Caspar pins. Satisfied with x-ray we then removed the Caspar pins and used bone wax for the holes. . We then used a Stryker Ozark view plate and placed 16 mm screws at C4 and C6 respectively under C-arm fluoroscopy. We placed a 12 mm screw into the graft in the center of the plate. Satisfied position we then final tightened the plate at all 3 sites. We then copiously irrigated with warm saline. We removed self-retaining retractor went back in with handheld Cloward any extraneous bleeding was controlled bipolar cautery. We then took final AP and lateral x-rays satisfied with this we then closed the platysmas muscle with interrupted 3-0 Vicryl the skin was closed running 4 Monocryl in a thin layer Dermabond placed on top. Patient tolerated procedure well without complication estimated blood loss was 100 mL IV fluids 1200 mL crystalloid. Patient was subsequently awakened extubated taken to PACU in good condition he will be off to med surge floor once satisfied PACU criteria