Susan Posted Thu 23rd of April, 2015 11:20:10 AM
Using multiple radiographic views, guide wires were inserted paraspinally, transforaminally into the disc spaces at L4-L5. These were confirmed on multiple radiographic views. Paraspinal incisions were made bilaterally. Incision sites were injected with a total of 20 cc of marcaine 0.25% with epinephrine 1:200,000. Paraspinal incisions were made bilaterally. Soft tissues were dissected down to the fascia.
The fascia was opened with a #10 blade and muscle dissection was carried down to the facet joints at L4-L5 bilaterally under direct visualization. Sequential dilators were then placed into the wound and carbon fiber working tube was placed. Dilators were removed. The foramen, lamina and facet were directly visualized. . A kerrison and burr were then used to perform a lamintomy/partial facectomy/foraminotomy.
One cc of mixture of 2 cc of Indigo carmine dye 0.8%, mixed with 18 cc of Isovue 200, was used to perform a discogram for tissue identification purposes. This was done in order to stain the disc material blue so as to differentiate it from the other neural elements.
Attention was turned to the right side at L4-L5. Using pituitaries, kerrisons and graspers, a laminotomy/foraminotomy/partial facetectomy and microdiscectomy for decompression was performed under direct visualization. This was carried back to the annulus. The tube was withdrawn back into the foramen, and the exiting and traversing nerve roots were identified, and found to be free of extrinsic pressure and protected throughout the case. The tube was then replaced back into the disc space. An annuloplasty was performed, using the Ellman probe, over the anterior, posterior, medial, and lateral annulus. The tube was withdrawn from the disc and the epidural space was explored.
Attention was turned to the right facet at L4-L5. The facet was directly visualized through the tubular retractor. Using the Ellman probe, the soft tissues were cleared from the capsule. The median branch nerve was identified and transected. A Kerrison and burr was used to further perform an open partial facetectomy/foraminotomy.
Attention was turned to the left facet at L4-L5. The facet was directly visualized through the tubular retractor. Using the Ellman probe, the soft tissues were cleared from the capsule. The median branch nerve was identified and transected. A Kerrison and burr was used to further perform an open partial facetectomy/foraminotomy.
Incisions were irrigated out well with 2000 ml of normal saline. A piece of gelfoam was placed in each incision to aid in hemostasis. The incisions were closed in multiple layers, using 0 Vicryl for deep fascia, 0 Vicryl for deep dermal, and 3-0 Monocryl for superficial dermal. The epidermis was sealed with dermabond. Sterile dressings were applied. The patient tolerated the procedure well and was placed into an LSO brace. All sponge, needle, and instrument counts were correct at the beginning and at the end of the case. Intraoperative neurophysiology was used throughout the case.
SuperCoder Answered Fri 24th of April, 2015 00:39:54 AM
AAE does not provide coding for operative reports and chart notes.
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