sdunaway1
Guru
Can you bill an X stop removal when performed w/ a plif at the same level? Is there an official code now for the removal? We have been told to use 22899 , but this hardly ever processes even w notes.
Thank you,
Stephanie
PREOPERATIVE DIAGNOSES:
1. L4-L5 high-grade stenosis.
2. L4-L5 unstable degenerative spondylolisthesis.
POSTOPERATIVE DIAGNOSES:
1. L4-L5 high-grade stenosis.
2. L4-L5 unstable degenerative spondylolisthesis.
OPERATION PERFORMED:
1. Removal of L4-L5 X-STOP device
2. L4-L5 decompressive laminectomy, bilateral foraminotomies, L4-L5.
3. L4-L5 posterior lumbar interbody fusion using the Rise cage from Globus Medical and then
autograft bone packed between on either side to the cages.
4. L4-L5 posterior lateral fusion with Vitoss autograft and allograft bone and pedicle
screw rod fixation using the CREO system from Globus Medical. .
5. Left iliac bone marrow aspiration for augmentation of the bony fusion.
6. X-rays x5 taken intraoperatively, all interpreted by Dr. Ganz.
PREOPERATIVE MEDICATION: Cefazolin 2 grams IV at induction, repeated 3 hours into the case.
PREOPERATIVE SUMMARY: The patient is a 77-year-old white male with a history of a X-STOP
device placed in 2009 for stenosis with good results. Approximately a year to 18 months
ago, he began to notice increasing low back pain affecting both of his legs, but right side
more prominently than the left. This has progressed despite conservative management and so
eventually repeat MRI scan was obtained, which showed progression of this high-grade
stenosis at the L4-L5 level with a prior X-STOP device in good position between the L4 and
L5 spinous processes. Because of the patient's progressive symptoms and the progression of
the stenosis on the MRI scan and the evidence of subluxation at the L4-L5 level, I did
recommend surgery. I did obtain preoperative flexion and extension x-rays, which showed
motion at the L4-L5 level indicating some instability. Because of this, I recommended not
only an L4-L5 decompressive laminectomy and foraminotomy, but also posterior lumbar
interbody and posterolateral fusion to stabilize the unstable L4-L5 segment. I did discuss
the surgical procedure with the patient. I did explain the potential benefits and risks of
surgery including potential risks of CSF leak, postoperative wound hematoma, the possibility
of increased pain, weakness and sensation loss in the left and/or right lower extremity
after surgery, the possibility of failure of the fusion requiring revision in the future,
the remote possibility of bowel or bladder dysfunction, the possibility of infection and the
risks of general anesthesia including the possibility of death. Mr. Halsted understood
these risks and he did consent to surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room on the PR cart
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 all pressure points were
carefully checked and padded. Skin overlying the lower lumbar spine was prepped and draped
off in a sterile manner using a double glove technique. I planned an incision in the
patient's prior incision, extending it approximately 3 cm above and then 2 cm below the
prior incision. A timeout was performed in the operating room where the case to be
performed was discussed including potential complications. We checked to make sure we had
all the equipment ready and available to perform the surgery. We did the usual preoperative
checklist.
At this time, an incision was carried out, carried down sharply to the lumbodorsal fascia.
Following this, a bilateral subperiosteal dissection along the lateral aspect of the spinous
processes of the inferior L3, all of L4, and L5 was carried out bilaterally, exposing the
interlaminar spaces in between. The X-STOP device was identified between the spinous
processes of L4 and L5 and this was disarticulated, then removed completely. Dissection was
carried laterally to expose the transverse processes of L4 and L5 bilaterally. X-rays were
carried out with markers on the L4 and L5 levels. This showed the markers at L4 and L5 as
expected. Before the markers were removed, they were marked with a suture for future
reference during surgery. I did interpret this x-ray myself in the operating room.
Following this, the self-retaining retractors were placed to hold the exposure. The
incision was irrigated with urosepsis, which is a dilute solution of chlorhexidine gluconate
allowed to sit for 1 minute and then it was suctioned out. Following this, interspinous
ligaments were divided at L3-L4. The entire spinous process of L4 was removed, as well as
the superior half of L5 and the inferior half of L3. The patient's bone was extremely hard
and dense. The lamina of L4 was drilled down to a thin eggshell of bone as well as the
inferior one-third of L3 and the superior half of L5. These were all drilled down to a thin
eggshell of bone and then removed with Kerrison rongeurs. There was a high-grade stenosis
at the L4-L5 level, primarily due to facet and ligamentous hypertrophy. The decompression
was carried laterally to decompress both lateral recesses and then foraminotomies of L4 and
L5 were carried out. The most significant foraminal stenosis at the L4-L5 foramina were the
L4 nerve root was exiting bilaterally. Also, the subluxation of L4 and L5 did contributed
to foraminal narrowing at the L4-L5 level. Once the decompression was completed which was a
fairly tedious procedure because of the patient's extremely hard bone. The L4 and L5 nerve
roots were again explored and found to be well decompressed within their respective
foramina.
At this time, left iliac bone marrow aspiration was carried out with aspiration of _____
from the left iliac crest. This was spun down and the cellular elements of this were then
used to augment the posterolateral fusion. The dorsal aspect of the transverse processes of
L4 and L5 were decorticated bilaterally as well as the lateral aspect of the facet joint at
L4-L5, again bilaterally, all to create a good bleeding bed for bone. Across this was laid
a piece of Vitoss soaked with bone marrow aspirate, over this was packed morselized
cancellous autograft and allograft bone to create a good posterolateral fusion mass.
A bilateral diskectomy was carried out at the L4-L5 level. This disk space was then
gradually dilated up. Once the inferior endplate of L4 and the superior endplate of L5 were
completely removed to create a good bleeding bed for bone. First from the left side an
expandable cage was placed using the Rise cage from Globus Medical. It was 10 x 26 mm and
then with expansion from 8-15 mm with 10 degrees of lordosis. Once the left-sided implant
was then placed, then from the right side morselized cancellous autograft bone was packed up
against the left-sided implant and then the right-sided implant was placed and expanded in
the same manner. This created a balanced _____ construct. Additional allograft was packed
on the lateral to both of the cages to fill the disk space completely with bone.
Following this, pedicle screws were placed in the L4 and L5 pedicles. We used a
stereotactic system from Stryker Medical. I did place 2 pins in the patient's right sacral
ala for rigid fixation of the stereotactic array to the patient.
OPERATIVE SUMMARY: The stereotactic array was then attached to it, tightened down and was
firmly seated and anchored in the patient's pelvis.
Using the stereotactic probe, the pedicles were probed under direct guidance using
stereotactic guidance and also with direct anatomic guidance. Screws were placed without
complication. I placed 6.5 x 55 mm screws in all 4 pedicles with good purchase obtained in
each of the pedicles. After the right-sided pedicle screws were placed, an x-ray was
repeated, which showed the pedicle screws in good position at the L4-L5 and the L4 and L5
pedicles. They were then placed from the left side. X-ray was repeated, which again showed
the pedicle screws properly placed at the L4-L5 level.
I should mention that an x-ray was also carried out. Once the L4-L5 disk space was exposed,
a marker was placed in this. A repeat lateral lumbar spine x-ray was carried out which
showed the marker in the L4-L5 disk space confirming the correct level. I did interpret all
the intraoperative x-rays myself in the operating room.
At this time, a 1/4-inch titanium alloy rod, again using the CREO system from Globus
Medical, was used to connect up the heads of the screws. Before the screws were tightened
down, they were placed under compression to load the facets and also to set the threads of
the screws to improve the overall strength of the construct. Once these were placed, final
lateral lumbar spine x-ray was carried out which showed indeed the interbody implant
expandable cages and the posterior pedicle screws and rods all properly placed with near
complete correction of the preoperative spondylolisthesis. Following this, the entire field
was then irrigated with bacitracin normal saline solution. Hemostasis was accomplished.
Gelfoam was placed in the gutters laterally and dorsally over the thecal sac. Two Hemovac
drains were placed in the epidural space, brought out through separate stab wound incisions
inferior and lateral to the incision. They were sutured at their exit point to prevent
premature removal. The 2 pins placed in the patient right sacral ala were removed. These
were small stab wounds, and direct pressure was applied to those for 4 minutes and then they
were removed with no active bleeding seen.
At this time, the incision was again irrigated with Aricept, allowed to sit for a minute and
then irrigated out with bacitracin and normal saline solution. Once hemostasis was
accomplished, the incision was closed in layers up to the fascia.
At this time, 20 mL of Exparel was injected into the subcutaneous tissues. It was diluted
up to 60 mL and 30 mL was injected on either side to aid in postoperative incisional pain.
At this time, the subcutaneous fatty layer was closed, followed by the subdermal layer and
then the skin was closed with a subcuticular stitch. The incision was covered with Prineo
dressing which is a bacteriostatic mesh with wound glue to create a waterproof dressing.
Over this was laid Telfa, sterile 4 x 4's which were taped to the patient's back. The
patient was then maneuvered back into supine position on the PR cart where he underwent
successful reversal of general anesthesia and extubation in the operating room. He was
moving both lower extremities well at the end of the procedure and left the operating room
in stable condition.
Thank you,
Stephanie
PREOPERATIVE DIAGNOSES:
1. L4-L5 high-grade stenosis.
2. L4-L5 unstable degenerative spondylolisthesis.
POSTOPERATIVE DIAGNOSES:
1. L4-L5 high-grade stenosis.
2. L4-L5 unstable degenerative spondylolisthesis.
OPERATION PERFORMED:
1. Removal of L4-L5 X-STOP device
2. L4-L5 decompressive laminectomy, bilateral foraminotomies, L4-L5.
3. L4-L5 posterior lumbar interbody fusion using the Rise cage from Globus Medical and then
autograft bone packed between on either side to the cages.
4. L4-L5 posterior lateral fusion with Vitoss autograft and allograft bone and pedicle
screw rod fixation using the CREO system from Globus Medical. .
5. Left iliac bone marrow aspiration for augmentation of the bony fusion.
6. X-rays x5 taken intraoperatively, all interpreted by Dr. Ganz.
PREOPERATIVE MEDICATION: Cefazolin 2 grams IV at induction, repeated 3 hours into the case.
PREOPERATIVE SUMMARY: The patient is a 77-year-old white male with a history of a X-STOP
device placed in 2009 for stenosis with good results. Approximately a year to 18 months
ago, he began to notice increasing low back pain affecting both of his legs, but right side
more prominently than the left. This has progressed despite conservative management and so
eventually repeat MRI scan was obtained, which showed progression of this high-grade
stenosis at the L4-L5 level with a prior X-STOP device in good position between the L4 and
L5 spinous processes. Because of the patient's progressive symptoms and the progression of
the stenosis on the MRI scan and the evidence of subluxation at the L4-L5 level, I did
recommend surgery. I did obtain preoperative flexion and extension x-rays, which showed
motion at the L4-L5 level indicating some instability. Because of this, I recommended not
only an L4-L5 decompressive laminectomy and foraminotomy, but also posterior lumbar
interbody and posterolateral fusion to stabilize the unstable L4-L5 segment. I did discuss
the surgical procedure with the patient. I did explain the potential benefits and risks of
surgery including potential risks of CSF leak, postoperative wound hematoma, the possibility
of increased pain, weakness and sensation loss in the left and/or right lower extremity
after surgery, the possibility of failure of the fusion requiring revision in the future,
the remote possibility of bowel or bladder dysfunction, the possibility of infection and the
risks of general anesthesia including the possibility of death. Mr. Halsted understood
these risks and he did consent to surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room on the PR cart
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 all pressure points were
carefully checked and padded. Skin overlying the lower lumbar spine was prepped and draped
off in a sterile manner using a double glove technique. I planned an incision in the
patient's prior incision, extending it approximately 3 cm above and then 2 cm below the
prior incision. A timeout was performed in the operating room where the case to be
performed was discussed including potential complications. We checked to make sure we had
all the equipment ready and available to perform the surgery. We did the usual preoperative
checklist.
At this time, an incision was carried out, carried down sharply to the lumbodorsal fascia.
Following this, a bilateral subperiosteal dissection along the lateral aspect of the spinous
processes of the inferior L3, all of L4, and L5 was carried out bilaterally, exposing the
interlaminar spaces in between. The X-STOP device was identified between the spinous
processes of L4 and L5 and this was disarticulated, then removed completely. Dissection was
carried laterally to expose the transverse processes of L4 and L5 bilaterally. X-rays were
carried out with markers on the L4 and L5 levels. This showed the markers at L4 and L5 as
expected. Before the markers were removed, they were marked with a suture for future
reference during surgery. I did interpret this x-ray myself in the operating room.
Following this, the self-retaining retractors were placed to hold the exposure. The
incision was irrigated with urosepsis, which is a dilute solution of chlorhexidine gluconate
allowed to sit for 1 minute and then it was suctioned out. Following this, interspinous
ligaments were divided at L3-L4. The entire spinous process of L4 was removed, as well as
the superior half of L5 and the inferior half of L3. The patient's bone was extremely hard
and dense. The lamina of L4 was drilled down to a thin eggshell of bone as well as the
inferior one-third of L3 and the superior half of L5. These were all drilled down to a thin
eggshell of bone and then removed with Kerrison rongeurs. There was a high-grade stenosis
at the L4-L5 level, primarily due to facet and ligamentous hypertrophy. The decompression
was carried laterally to decompress both lateral recesses and then foraminotomies of L4 and
L5 were carried out. The most significant foraminal stenosis at the L4-L5 foramina were the
L4 nerve root was exiting bilaterally. Also, the subluxation of L4 and L5 did contributed
to foraminal narrowing at the L4-L5 level. Once the decompression was completed which was a
fairly tedious procedure because of the patient's extremely hard bone. The L4 and L5 nerve
roots were again explored and found to be well decompressed within their respective
foramina.
At this time, left iliac bone marrow aspiration was carried out with aspiration of _____
from the left iliac crest. This was spun down and the cellular elements of this were then
used to augment the posterolateral fusion. The dorsal aspect of the transverse processes of
L4 and L5 were decorticated bilaterally as well as the lateral aspect of the facet joint at
L4-L5, again bilaterally, all to create a good bleeding bed for bone. Across this was laid
a piece of Vitoss soaked with bone marrow aspirate, over this was packed morselized
cancellous autograft and allograft bone to create a good posterolateral fusion mass.
A bilateral diskectomy was carried out at the L4-L5 level. This disk space was then
gradually dilated up. Once the inferior endplate of L4 and the superior endplate of L5 were
completely removed to create a good bleeding bed for bone. First from the left side an
expandable cage was placed using the Rise cage from Globus Medical. It was 10 x 26 mm and
then with expansion from 8-15 mm with 10 degrees of lordosis. Once the left-sided implant
was then placed, then from the right side morselized cancellous autograft bone was packed up
against the left-sided implant and then the right-sided implant was placed and expanded in
the same manner. This created a balanced _____ construct. Additional allograft was packed
on the lateral to both of the cages to fill the disk space completely with bone.
Following this, pedicle screws were placed in the L4 and L5 pedicles. We used a
stereotactic system from Stryker Medical. I did place 2 pins in the patient's right sacral
ala for rigid fixation of the stereotactic array to the patient.
OPERATIVE SUMMARY: The stereotactic array was then attached to it, tightened down and was
firmly seated and anchored in the patient's pelvis.
Using the stereotactic probe, the pedicles were probed under direct guidance using
stereotactic guidance and also with direct anatomic guidance. Screws were placed without
complication. I placed 6.5 x 55 mm screws in all 4 pedicles with good purchase obtained in
each of the pedicles. After the right-sided pedicle screws were placed, an x-ray was
repeated, which showed the pedicle screws in good position at the L4-L5 and the L4 and L5
pedicles. They were then placed from the left side. X-ray was repeated, which again showed
the pedicle screws properly placed at the L4-L5 level.
I should mention that an x-ray was also carried out. Once the L4-L5 disk space was exposed,
a marker was placed in this. A repeat lateral lumbar spine x-ray was carried out which
showed the marker in the L4-L5 disk space confirming the correct level. I did interpret all
the intraoperative x-rays myself in the operating room.
At this time, a 1/4-inch titanium alloy rod, again using the CREO system from Globus
Medical, was used to connect up the heads of the screws. Before the screws were tightened
down, they were placed under compression to load the facets and also to set the threads of
the screws to improve the overall strength of the construct. Once these were placed, final
lateral lumbar spine x-ray was carried out which showed indeed the interbody implant
expandable cages and the posterior pedicle screws and rods all properly placed with near
complete correction of the preoperative spondylolisthesis. Following this, the entire field
was then irrigated with bacitracin normal saline solution. Hemostasis was accomplished.
Gelfoam was placed in the gutters laterally and dorsally over the thecal sac. Two Hemovac
drains were placed in the epidural space, brought out through separate stab wound incisions
inferior and lateral to the incision. They were sutured at their exit point to prevent
premature removal. The 2 pins placed in the patient right sacral ala were removed. These
were small stab wounds, and direct pressure was applied to those for 4 minutes and then they
were removed with no active bleeding seen.
At this time, the incision was again irrigated with Aricept, allowed to sit for a minute and
then irrigated out with bacitracin and normal saline solution. Once hemostasis was
accomplished, the incision was closed in layers up to the fascia.
At this time, 20 mL of Exparel was injected into the subcutaneous tissues. It was diluted
up to 60 mL and 30 mL was injected on either side to aid in postoperative incisional pain.
At this time, the subcutaneous fatty layer was closed, followed by the subdermal layer and
then the skin was closed with a subcuticular stitch. The incision was covered with Prineo
dressing which is a bacteriostatic mesh with wound glue to create a waterproof dressing.
Over this was laid Telfa, sterile 4 x 4's which were taped to the patient's back. The
patient was then maneuvered back into supine position on the PR cart where he underwent
successful reversal of general anesthesia and extubation in the operating room. He was
moving both lower extremities well at the end of the procedure and left the operating room
in stable condition.