Nervous SkullBase slide20 - AAPC

[Pages:2]Documentation Dissection

PREOPERATIVE DIAGNOSIS: Left frontal tumor.

POSTOPERATIVE DIAGNOSIS: Left frontal tumor |1|.

PROCEDURE PERFORMED: Left frontal bone flap craniotomy for resection of tumor |2|.

SPECIMENS: Tumor specimen sent for frozen, which came back as ependymoma |3| as well as sample sent for permanent pathology, and we sent brain tumor cyst fluid for cytology.

DRAINS: Jackson-Pratt drain in the subgaleal space.

IN: 150 of crystalloid with 200 ml of packed red blood cells.

OUT: Approximately 1020 ml urine output.

COMPLICATIONS: None.

CONDITION: Stable to PCU.

INDICATIONS FOR PROCEDURE: The patient is a 2-year-old girl with an approximately 2-1/2-week history of progressive right-sided weakness. She came to the emergency room where a noncontrast head CT showed evidence of a left frontal enhancing mass with a large cystic component |4|. She was admitted and underwent full cranial access MRI imaging, which showed no evidence of metastasis to the spine and confirmed the left frontal mass. Risks, benefits and alternatives were discussed with the parents and they have decided to move forward with surgery.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to operating room and general endotracheal anesthesia was induced without complication. The patient's bed was then repositioned 90 degrees. She was placed in a Mayfield frame with pediatric pins. An official timeout was performed. The frame was then attached to the Mayfield headholder and secured in place |5|. She was in a prone position. We marked out an incision on the scalp in a bicoronal fashion |6|. The hair overlying this planned incision was shaved. We then injected with local anesthetic. The patient was then prepped and draped in standard sterile fashion.

The skin was incised using a 15 blade and was taken down to the skull. Bovie electrocautery was also used to incise through the pericranium. We used periosteals to reflect the skin flaps. We used penetrating towel clamp attached to a rubber band and Allis clamps to reflect the skin flap posteriorly. We identified the coronal suture and the superior sagittal suture. We created burr holes |7| using a high speed Mid?s drill and perforating bits on the left side, approximately 5 cm from midline, as well as on the right side, just several centimeters lateral to the midline. We used Penfield 3 instruments to strip the dura. We then switched to a Midas footplate and completed the craniotomy. There were no dural tears. The bone flap was removed. We opened the dura in a U-shaped fashion and reflected it towards the superior sagittal sinus |7|. We used 4-0 Vicryl sutures to reflect the dural leaf. We used bipolar electrocautery to cauterize the pial surface. Then we incised using an 11 blade. We passed an EVD catheter into the cystic component of the mass, using ultrasound guidance. We were able to send off approximately 20 ml of xanthochronic fluid for cytology |8|.

We began with internal debulking of the tumor using suction and bipolar once we were below the pial layers. We sent off specimens for frozen pathology. We continued to internally debulk the tumor using suction as well as CUSA. We were able to identify the tumoral and brain margin and we were able to define this plane. We used the Leyla bar with snake retractors to aid in exposure. We worked in a systematic fashion in quadrants to internally debulk and then find the tumoral brain interface. Bipolar electrocautery was used for hemostasis. This resection was performed under loupe magnification and headlight |9|.

Once we were satisfied that we had achieved a gross total resection, inspected the cavity, and had adequate hemostasis, we proceeded to close. We used 4-0 Vicryl suture to close the dura. The bone was replaced and secured to the skull using 3 plates and 6 screws. We used the previously saved bone dust to fill in the burr holes. We then placed a JP drain underneath the galea. We proceeded to close using 2-0 and 3-0 Vicryl sutures in the galeal layer followed by a 4-0 plain gut suture at the skin. The patient was then awaken and taken to PACU and extubated in stable condition. All sponge and needle counts were correct x 2.

1

_____________________________________________________________ |1| Postoperative diagnosis is left frontal tumor. No indication of histology of the tumor; review information in body of operative report. |2| Planned procedure is the resection of the tumor, with the approach a left frontal craniotomy. Confirm procedures in the body of the operative report. |3| Frozen specimen was sent during the procedure and came back as an ependymoma, which is malignant. |4| Verification of the left frontal mass with cystic components. |5| The head is immobilized to perform the procedure. |6| The incision is bicoronal, which is the frontal craniotomy. |7| Creation of burr holes (trephination). Bone flap craniotomy with removal of the top part of the skull, which was replaced at the end of the case. |8| There was a cyst filled with fluid, associated with the mass on ultrasound, that was aspirated for pathology. |9| The resection of the tumor was performed, which is the definitive procedure. The ventricles are below the pial layers.

_____________________________________________________________ What are the CPT? and ICD-10-CM codes reported? CPT? Codes: 61510, 76942-26 ICD-10-CM Code: C71.5 Rationales: CPT?: This was a craniotomy with bone flap of the top part of the skull for excision and debulking of a left frontal brain mass/ tumor. The bone was replaced and secured with plates and screws at the end of the procedure. Report 61510. Look in the CPT? Index for Craniotomy/with Bone Flap for the list of codes. Ultrasound guidance was used to insert a catheter to drain 20 cc for fluid for cytology. Look in the CPT? Index for Ultrasound/Guidance/Needle biopsy for 76942. Modifier 26 is needed for the professional service. Drainage of the cyst within the tumor is included in the removal/debulking of the tumor. ICD-10-CM: An ependymoma is a tumor that arises from the ependymal cells that line the ventricles of the brain and is malignant. In the ICD-10-CM Neoplasm Table, locate brain/ventricle, which refers to C71.5. Verification in the Tabular List identifies C71.5 Malignant neoplasm of the cerebral ventricle, as the correct code.

2

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download