Nervous LaminotomyLaminectomy slide26 - AAPC
嚜澳ocumentation Dissection
Operative Report
PREOPERATIVE DIAGNOSIS; Left L4 radiculopathy secondary to L4每5 herniated nucleus pulposus and left L5每S1 foraminal
stenosis.
POSTOPERATIVE DIAGNOSIS: Left L4 radiculopathy secondary to L4每5 herniated nucleus pulposus and left L5每S1 foraminal
stenosis |1|.
OPERATION PERFORMED: Left L4每5 microdiscectomy and left L5每S1 foraminotomy |2|.
INDICATIONS FOR PROCEDURE: This is a 64-year-old right-handed white female who was initially evaluated in 06/2009
with symptoms of left-sided lumbosacral back pain. Initial workup did not reveal any significant pathology in the lumbar spine
to account for her symptoms of pain. Although, she did have a low-grade spondylolisthesis at L5每S1 with bilateral foraminal
narrowing, the patient did not, however, have clear symptoms of radicular pain in the L5 distribution. A series of injections were
performed, the last in December, and since that lime, the patient has now had new symptoms of pain in the left lower extremity
that travels from the left gluteal and hip region into the left anterior thigh. As a result of this new pain, an MRI scan was performed
last week, which reveals the patient to have a large extruded disk herniation from the L4每5 disk space extending cranially directly
into the left L4 nerve root |3|. On evaluation three days ago, the patient was noted to also have mild weakness in the left iliopsoas
and left quadriceps muscles as well as numbness along the medial aspect of the left calf. Based on her increasing symptoms of
pain as well as development of weakness in the left leg, the patient presents now for elective decompression of her left L4每5 disk
herniation. In view of the known foraminal stenosis on the left L5每SI, a left L5每S1 foraminotomy will also be performed |4|.
PROCEDURE IN DETAIL: The patient was brought to the operating room, and after adequate endotracheal anesthesia |5| was
obtained, a Foley catheter was placed, and the patient was then turned prone onto the operating table with the chest and abdomen
supported with a Kambin frame |6|. The patient*s head was maintained in neutral position on a foam headrest. Localizing images |7|
of the lumbar spine were then taken identifying the L4每5 and L5每S1 levels. The lumbar region was then prepped and draped in the
usual fashion. A midline lumbar incision was then made, and this was carried down to the lumbodorsal fascia, and this was incised
unilaterally on the left side |8|. The paraspinal muscles were then dissected free from the spinous process and lamina on the left side
and initial retraction over the L4每5 level was obtained with the use of a Taylor retractor. A 3 mm Kerrison punch was then used to
create an initial laminotomy and this was further widened with the use of 0.25% osteotome. The superior aspect of the L5 lamina
was then resected freeing the underlying ligamentum flavum and this was carried laterally to involve the medial aspect of the L5每
S1 facet superior articular process. The underlying intervening ligamentum flavum was removed exposing the dura and epidural
veins were then coagulated and cut. Palpation in the epidural space revealed the presence of a prominent bulge arising from the
L4每5 disk space, but with manipulation in the epidural space toward the exiting L4 nerve root, multiple fragments of disk |9|
material were then encountered consistent with a free fragment disk rupture. These fragments were then slowly removed. The disk
space was also incised and additional loose disk malarial was removed from within the L4每5 disk space. The remaining annulus
and the posterior longitudinal ligament was then further lightened with the use of bipolar cautery. At this point, it appeared that
the exiting L4 nerve root was adequately decompressed |10| and no additional disk fragments were encountered. The disk material
was sent for pathologic evaluation. Liquid Gelfoam was then placed in the epidural space with good hemostasis.
Attention was then directed to the L5每S1 level and the interior aspect of the L5 lamina was identified, but on further examination
of the L5 lamina, it was noted that the distance from the right to left across the pars was relatively narrow and based on the location
of the foraminal stenosis, it was then elected to proceed with the lateral extraforaminal approach for decompression of the exiting
L5 foramen |11|. Soft tissue overlying the superior articular process of the SI was then resected with the Kerrison punch and this
was carried down to the lateral pars. Additional soft tissue was removed here and the lateral margin of the pars was then fully
dissected with the use of curettes and on its superior side, the L5 transverse process was identified. Ligamentum flavum extending
from below the lamina to be incorporated into the facet capsule was then identified and removed and eventually fat within the
epidural space around the L5 nerve root was encountered. Additional bone along the transverse process as well as ligamentous
material extending into the foremen was then removed. At this point, the exiting L5 foremen appeared to be adequately patent.
Liquid Gelfoam was then placed in the foramen with good hemostasis. The wound was then irrigated with bacitracin irrigation.
The Taylor retractor, which had been redirected down to the L5每S1 level was removed and the wound was then closed in layers. The
fascial layer with 0 Vicryl in a running fashion. 0.5% Marcaine with epinephrine to a volume of 10 mL was then Injected into the
paraspinal muscles as well as below the fascial layer. The subcutaneous layers were closed with 3-0 Vicryl in an interrupted fashion,
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as well as the subdermal layer. The skin was closed with a 4-0 Monocryl subcuticular stitch. At the conclusion of surgery, all sponge
and needle counts were correct. The patient tolerated the procedure well. At this point, the wound margins were then coated with
Benzoin, and Steri-Strips were applied. Sterile dressing was placed over this and the patient was then turned supine onto a waiting
bed, and transported to the recovery room in stable condition |12|. Of note, the operating microscope was brought in once the initial
laminotomy at L4每5 had been completed and the remainder of the procedure at L4每5 as well as L5每S1 was done under microscopic
magnification.
_____________________________________________________________
|1|
Indication and medical necessity for procedure.
|2|
Procedure performed 每 level identified as L5-S1.
|3|
Findings confirmed by MRI.
|4|
Symptoms of stenosis.
|5|
Type of anesthesia.
|6|
Kambin frame is designed to provide stabilization to the patient, allowing imaging during the procedure.
|7|
Imaging performed.
|8|
Incision at lumbar level, left side.
|9|
Discectomy for bulging disc.
|10|
Decompression of L4 nerve root.
|11|
Second level decompressed L5每S1.
|12|
Closure of the surgical site and status of patient.
_____________________________________________________________
What are the CPT? and ICD-10-CM codes reported?
CPT? Codes: 63030-LT, 63035-LT
ICD-10-CM Code: M51.16, M99.83
Rationales:
CPT?: The procedure performed was a laminectomy with removal for disk and fragments at L4每L5 and forminotomy of L5每S1 on
the left side. In the CPT? Index, look for Hemilaminectomy referring you to code range 63020-63044. Code 63030 for the lumbar
is correct. Modifier LT is used to denote the left side. Also performed was a foraminotomy at L5每S1 for decompression of the
L5每S1 nerve root on the left side. Report add-on code 63035-LT. Do not report 77002 for fluoroscopic guidance and the operating
microscope, as both are included in 63030 per NCCI edits.
ICD-10-CM: The diagnosis is herniated disc with radicular neuropathy. Look in the ICD-10-CM Alphabetic Index for Hernia/
intervertebral cartilage or disc〞see Displacement, intervertebral disc. Next look for Displacement/intervertebral disc NEC/
Lumbar region/with/neuritis, radiculitis, radiculopathy or sciatica referring you to M51.16. There was a foraminal stenosis at L5-S1.
Next, look in the Alphabetic Index for Stenosis/intervertebral foramina - (see also Lesion, biomechanical, specified NEC). Look in
the Alphabetic Index for Lesion/biomechanical/specified type/lumbosacral directing you to M99.83. Verify in the Tabular List.
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