Please help - Doctor does stress fracture repair at L5 with pedicle hooks
My thoughts are CPT codes: 22325; 22840;and 20936
(please see op note below)
OPERATION: L5 spondylolysis repair with iliac crest bone graft and DePuy 5.5 titanium instrumentation.
BLOOD LOSS: 75 cc.
INDICATIONS FOR SURGERY: This is a child who has a long history of back pain. She is an aggressive athlete, and we have been unable to handle her pain conservatively. They come for spondylolysis repair. This was chosen over a fusion, as she again is a very active athlete and has demands on her back. They do understand that there is a somewhat increased risk of failure with L5 repairs. They understand the risks which include medical complications, blood loss, infection, neurologic injury, failure and need for revision surgery or fusion.
DESCRIPTION OF PROCEDURE:
She was given a general anesthetic. She was placed in a well-padded prone position. She was given preoperative Ancef. Appropriate time-out was done. Approximately a 4-5 cm incision was made using fluoroscopy to localize. This was carried through the skin and
subcu. The fascia was identified. We made 2 separate fascial incisions
with a Wiltse approach. We started on the left side. We split the muscle and came down on the pars. We used fluoro to help guide us. We found the defect and visualized it as well as confirmed it on fluoro, and debrided this thoroughly. On this side we did drill the edges of the defect to get some bleeding bone. This was done with a 2 mm bur. We then obtained our fixation. We placed a pedicle screw without disturbing the capsule at L5. We then placed an inferior laminar hook at the inferior lamina at L5 on that left side. We obtained bone graft from both sides from the right iliac crest. We exposed the crest and then used a Synthes large ex-fix trocar to harvest the bone. Several plugs were taken and used. We filled the defect thoroughly and the edges around the defect. We then did the
exact same surgery on the right side. She had much better bleeding
surfaces on that side; therefore, there was no need for drilling. We
placed the screw again at L5 and the hook inferior laminar at L5. We then compressed the right side, followed by the left side. Final tightening was done on both sides. The wounds were irrigated out prior to graft placement. The wounds were then closed with a deep fascial stitch on each side, followed by a subcutaneous subcuticular stitch. During obtaining our final x-rays, before the child was awakened or the drapes removed, we did notice that the right rod had pulled up inferiorly or distally from the hook. We opened up on that side again and replaced the rod and loosened and the set screws, compressed again across the defect, rechecking our graft and tightened both screws. Again all screws were final tightened
with the torque wrench. A closure was repeated on that side and also withthe subcu and subcuticular skin stitch. Stitches were also placed in the small iliac crest incision. She was awakened and taken to the recovery room stable condition with normal neuro exam. She tolerated the procedure well. There were no complications.