Requesting assistance with this particular case. Thank you so much who can assist.
Coder selection: 22633, 22840, 22853, 63051,63052, 20936 ( 2nd guessing myself) due to the removal of the synovial cyst in the nerve root.
vs
Provider code section: 22633, 22840, 22853, 22010, 63047, 63048, 20936
PREOPERATIVE DIAGNOSIS:
1. Degenerative spinal listhesis L4-5.
2. Lumbar spondylosis with radiculopathy.
3. Synovial cyst right L4-5.
POSTOPERATIVE DIAGNOSIS:
Same.
PROCEDURES:
1. Transforaminal lumbar interbody fusion L4-5.
2. Posteriorlateral Lumbar spinal fusion L4-5.
3. Posterior spinal instrumentation L4-5.
4. Placement of a biomechanical intervertebral cage/device using the NANOVIS intervertebral spacer at L4-5
5. Excision of posterior vertebral intrinsic lesion right L4-5 synovial cyst.
6. Use of bone morphogenic protein using the infuse system at L4-5.
7. Use of fresh frozen allograft/crushed cancellous bone.
After fully informed consent was obtained from the patient the patient was then taken to the operating room and underwent general endotracheal intubation. The patient was provided 2 g of Ancef prior to commencement of the procedure. After which the patient was then positioned on the operating table using a Jackson frame in the prone position. All bony prominences were well-padded. The posterior
lumbar region was then prepped and draped in the normal sterile fashion. The fluoroscope was then brought in to ensure we were at the L4-5 level. With the use of a scalpel an incision was made extending from the L3 spinous process to the L5 spinous process. A Bovie was used for hemostasis. Dissection was made down through the skin subcutaneous and fat tissue down to the posterior lumbar spinous processes and fascia. A repeat fluoroscopic image was obtained to ensure that we are at the proper levels. With the use of a Cobb elevator and a Bovie a subperiosteal dissection was then performed along the spinous processes and down to the lamina and out to the facet joint complex extending from the L3-4 level. Careful attention was ascertained to protect the L3-4 facet joint but to expose the transverse process and mamillary process of the L4 vertebrae. Dissection was made out laterally to the transverse processes of the L4 vertebrae. After adequate exposure was obtained our attention was then brought to the left side to identify the mamillary process of the L4 vertebrae. A high-speed bur was used to make a entry hole in the cortical bone followed by a pedicular awl which was advanced into the pedicle and into the vertebral body. After which a sound was placed into the pilot hole to be certain that we are within the pedicle followed by placement of a tap and then repeat sounding of the pilot hole that had been tapped and lastly placement of a Get Set pedicle screw. After this was completed the process was duplicated identical fashion at the L5 level. The fluoroscope was then brought in ascertain placement of the left-sided pedicle screws and were found to be in good position. The procedure was then duplicated identical fashion on the contralateral right side. The fluoroscope was again brought in to ascertain position of the pedicle screws and were all found to be in good position. With the use of a gouge the L4-5 facet joints were partially removed on the left side and completely removed along the right side. A complete and total facetectomy foraminectomy and removal of the intrinsic synovial cyst was done with visualization of the descending L5 and exiting L4 nerve root. After which along the right side a hemilaminectomy of the superior portion of the L5 lamina and
the entire right L4 lamina the ligamentum flavum was also removed. Were then able to identify the exiting L4 nerve root and the descending 5 nerve root. A nerve root retractor was then used to protect the exiting and descending nerve root and to retract the dura medially. The disc annulus was then identified. A bipolar Bovie was used for hemostasis within the canal. A window was then cut in the disc annulus in the transforaminal region followed by placement of various twisty type shavers to release the disc from the interbody space. Various pituitaries curettes were used to remove the bulk of the disc material. A capstone trial was placed with in the disc space to distract the intervertebral space and a working rod was placed along the pedicle screws on the contralateral side and locked into place to hold the disc space open. Further completion of the removal of all disc material down to the subchondral bone was then performed after adequate disc material was removed a rasp was then used to roughen up the endplates and obtain good punctate bleeding. After which various trial sizers using the NANOVIS interbody biomechanical device were used to determine the proper size cage to be inserted. Patient excepted a size 12 NANOVIS cage. Using fresh frozen allograft along with demineralized bone matrix the allo-graft was chopped up in small pieces and then was placed in a bone graft funnel inserter and placed within the anterior one third of the intervertebral space and impacted with a footed impactor. After which a bone morphogenic infuse sponge was placed posterior to the bone graft. Additionally a bone morphogenic infuse sponge was also placed within the NANOVIS cage. The cage was then inserted in an oblique direction towards the contralateral side and then impacted into the proper position. The fluoroscope was brought in to ascertain proper positioning and was found to be in good position. After this was completed the construct was then placed under compression posteriorly along the pedicle screws and rods and locked into place with a locking knot. The fluoroscope again was brought in ascertain the completed construct and was found to be in good position. The transverse processes was then decorticated with a high-speed bur. The remaining fresh frozen cortical cancellous bone was then placed posterior laterally. The annular windows were sealed with fibrin glue. After which the wound was then vigorously irrigated with 3 L of pulsatile lavage. A fat graft was obtained from sub-cutaneous tissue sharply a Bovie was used for hemostasis. The fat graft was then injected with 50 mcg of fentanyl and 40 mg of Kenalog. The fat graft was then placed over the transforaminal site for local pain control.
Additional fibrin glue was placed over the fat graft. Xperian was placed within the wound and let sit for approximately 5 minutes. After adequate hemostasis was obtained 2 g of vancomycin powder was placed within the wound 1 g deep and 1 g superficial a medium size Hemovac was then placed in the deep layer and then the fascia was closed with an interrupted #1 Vicryl followed by 2-0 Vicryl 3-0 Monocryl and Dermabond for skin.
Coder selection: 22633, 22840, 22853, 63051,63052, 20936 ( 2nd guessing myself) due to the removal of the synovial cyst in the nerve root.
vs
Provider code section: 22633, 22840, 22853, 22010, 63047, 63048, 20936
PREOPERATIVE DIAGNOSIS:
1. Degenerative spinal listhesis L4-5.
2. Lumbar spondylosis with radiculopathy.
3. Synovial cyst right L4-5.
POSTOPERATIVE DIAGNOSIS:
Same.
PROCEDURES:
1. Transforaminal lumbar interbody fusion L4-5.
2. Posteriorlateral Lumbar spinal fusion L4-5.
3. Posterior spinal instrumentation L4-5.
4. Placement of a biomechanical intervertebral cage/device using the NANOVIS intervertebral spacer at L4-5
5. Excision of posterior vertebral intrinsic lesion right L4-5 synovial cyst.
6. Use of bone morphogenic protein using the infuse system at L4-5.
7. Use of fresh frozen allograft/crushed cancellous bone.
After fully informed consent was obtained from the patient the patient was then taken to the operating room and underwent general endotracheal intubation. The patient was provided 2 g of Ancef prior to commencement of the procedure. After which the patient was then positioned on the operating table using a Jackson frame in the prone position. All bony prominences were well-padded. The posterior
lumbar region was then prepped and draped in the normal sterile fashion. The fluoroscope was then brought in to ensure we were at the L4-5 level. With the use of a scalpel an incision was made extending from the L3 spinous process to the L5 spinous process. A Bovie was used for hemostasis. Dissection was made down through the skin subcutaneous and fat tissue down to the posterior lumbar spinous processes and fascia. A repeat fluoroscopic image was obtained to ensure that we are at the proper levels. With the use of a Cobb elevator and a Bovie a subperiosteal dissection was then performed along the spinous processes and down to the lamina and out to the facet joint complex extending from the L3-4 level. Careful attention was ascertained to protect the L3-4 facet joint but to expose the transverse process and mamillary process of the L4 vertebrae. Dissection was made out laterally to the transverse processes of the L4 vertebrae. After adequate exposure was obtained our attention was then brought to the left side to identify the mamillary process of the L4 vertebrae. A high-speed bur was used to make a entry hole in the cortical bone followed by a pedicular awl which was advanced into the pedicle and into the vertebral body. After which a sound was placed into the pilot hole to be certain that we are within the pedicle followed by placement of a tap and then repeat sounding of the pilot hole that had been tapped and lastly placement of a Get Set pedicle screw. After this was completed the process was duplicated identical fashion at the L5 level. The fluoroscope was then brought in ascertain placement of the left-sided pedicle screws and were found to be in good position. The procedure was then duplicated identical fashion on the contralateral right side. The fluoroscope was again brought in to ascertain position of the pedicle screws and were all found to be in good position. With the use of a gouge the L4-5 facet joints were partially removed on the left side and completely removed along the right side. A complete and total facetectomy foraminectomy and removal of the intrinsic synovial cyst was done with visualization of the descending L5 and exiting L4 nerve root. After which along the right side a hemilaminectomy of the superior portion of the L5 lamina and
the entire right L4 lamina the ligamentum flavum was also removed. Were then able to identify the exiting L4 nerve root and the descending 5 nerve root. A nerve root retractor was then used to protect the exiting and descending nerve root and to retract the dura medially. The disc annulus was then identified. A bipolar Bovie was used for hemostasis within the canal. A window was then cut in the disc annulus in the transforaminal region followed by placement of various twisty type shavers to release the disc from the interbody space. Various pituitaries curettes were used to remove the bulk of the disc material. A capstone trial was placed with in the disc space to distract the intervertebral space and a working rod was placed along the pedicle screws on the contralateral side and locked into place to hold the disc space open. Further completion of the removal of all disc material down to the subchondral bone was then performed after adequate disc material was removed a rasp was then used to roughen up the endplates and obtain good punctate bleeding. After which various trial sizers using the NANOVIS interbody biomechanical device were used to determine the proper size cage to be inserted. Patient excepted a size 12 NANOVIS cage. Using fresh frozen allograft along with demineralized bone matrix the allo-graft was chopped up in small pieces and then was placed in a bone graft funnel inserter and placed within the anterior one third of the intervertebral space and impacted with a footed impactor. After which a bone morphogenic infuse sponge was placed posterior to the bone graft. Additionally a bone morphogenic infuse sponge was also placed within the NANOVIS cage. The cage was then inserted in an oblique direction towards the contralateral side and then impacted into the proper position. The fluoroscope was brought in to ascertain proper positioning and was found to be in good position. After this was completed the construct was then placed under compression posteriorly along the pedicle screws and rods and locked into place with a locking knot. The fluoroscope again was brought in ascertain the completed construct and was found to be in good position. The transverse processes was then decorticated with a high-speed bur. The remaining fresh frozen cortical cancellous bone was then placed posterior laterally. The annular windows were sealed with fibrin glue. After which the wound was then vigorously irrigated with 3 L of pulsatile lavage. A fat graft was obtained from sub-cutaneous tissue sharply a Bovie was used for hemostasis. The fat graft was then injected with 50 mcg of fentanyl and 40 mg of Kenalog. The fat graft was then placed over the transforaminal site for local pain control.
Additional fibrin glue was placed over the fat graft. Xperian was placed within the wound and let sit for approximately 5 minutes. After adequate hemostasis was obtained 2 g of vancomycin powder was placed within the wound 1 g deep and 1 g superficial a medium size Hemovac was then placed in the deep layer and then the fascia was closed with an interrupted #1 Vicryl followed by 2-0 Vicryl 3-0 Monocryl and Dermabond for skin.