I HAVE 721.3, 724.2 AND 63688 - What am I missing?
POSTOPERATIVE DIAGNOSIS: 1. Low back pain secondary to lumbar spondylosis and spinal stimulator generator.
PROCEDURE: 1. Removal of spinal stimulator generator.
ANESTHESIA: Intravenous sedation.
INDICATIONS FOR PROCEDURE: The patient is an 85-year-old female status post L2-3 laminectomy and fusion back in 2007 with implantable bone stimulator. The patient states her radicular pain has resolved, however she has persistent back pain and feels that the generator from the stimulator is quite irritating to her back pain and desires it to be removed. Risks and complications were discussed at great length. The patient clearly understands and desires to proceed as outlined above.
DESCRIPTION OF PROCEDURE: The patient was brought into the holding area and was given 2 grams of Ancef intravenously for antimicrobial prophylaxis as well as the application of sequential compression devices for the prevention of deep vein thrombosis. The patient was then taken to the operating room and was placed in the left lateral decubitus position, and after an adequate level of intravenous sedation, the lumbar region was then shaved, prepped, and draped in usual sterile fashion. Skin was infiltrated with 0.25% Marcaine with epinephrine.
Incision was made over the generator in the right upper lumbar region with a #10 blade through the skin and subcutaneous tissues using Bovie cautery. The capsule surrounding the generator was opened, and then using blunt and sharp dissection the generator was mobilized and then pulled out of the wound and disconnected from its leads.
Hemostasis was achieved with bipolar cautery. The wound was copiously irrigated with antibiotic solution. The wound was then closed in a physiologic fashion with 2-0 Vicryl simple interrupted stitches for the subcutaneous tissue and stainless steel staples for the skin. Sterile dressings were applied.
The patient tolerated the procedure well without complications. All counts were correct.
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