I am unable to find correct code...op note below...
History of gunshot wound
Spinal cord tethering
Progreessive spinal cord dysfunction
Bilateral T9, 10, 11 laminectomy with laminoplasty.
Intradural spinal cord de-tethering T10-11.
Microsurgical dural closure.
Reconstruction of posterior thoracic spinal elements, T9, 10, 11.
Codes provided by surgeon: 63200, 63295
Localizing xray was used to verify correct levels. At this point the bullet fragment itself was identified on the pt right side at approximately the level of the T11 pedicle. This was carefully exposed from within the soft tissue immediately adjacent to the spine and this was removed in a single fragment . At this point with appropriate levels verified, curette and Kerrison instruments were used to create a small laminotomy at the inferior aspect of T11 bilaterally. Next the stryker drill was placed and, working from the inferior aspect of T11, working first on one side then the other, a drill cut was created through the lamina of T11, T10, T9. Ligaments were cut using heavy scissors and, at this point, the T9, 10, and 11 lamina and spinous processes were removed as a single unit. Using microsurgical technique, a small amount of remaining bone and ligament was removed using Kerrison instruments to fully expose the dura through this region. There were obvious small metallic fragments in the dura itself. There was an area of scarring in the dura which was felt to be immediately over the site of dural tethering. At this point, Floseal was placed in the gutters and, using microsurgical technique, working above and below the level of presumed dural tethering, a #11 blade was used to create a small dural entry. This was extended slightly superiorly and inferiorly and then, working slowly towards the area of tethering. At this point 4-0 Nurolon sutures were used to carefully hold up the sides of the dura. Intradural dissection was carefully performed. Arachnoid was carefully freed away and above and below the area of tethering, the spinal cord was noted t have minimal to no adhesions. However, it could be visualized to clearly be extending up and adherent to the dura. At this point, decision was made to create a small island of dura that would be left attached to the spinal cord to allow it to be de-tethered and float away. The goal was to minimize spinal cord dissection and also to try to prevent an area of significant inflammation which would be likely cause of re-tethering. So, in this manner, the dural opening above and below the area of tethering was carefully extended first to the right and then to the left around the area of tethering. Once the dural cuts were made, intradural microsurgical dissection was used to carefully free up the remaining arachnoid adhesions, and upon completion of this, very obvious release of the spinal cord was accomplished with the spinal cord moving anteriorly and suddenly having nice pulsations.
Thank you to anyone who can provide insight on this procedure!
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