I need help with coding of this procedure.
T12 metastatic cancer with pathologic fracture.
Open reduction and internal fixation of T12 pathologic fracture
via posterior corpectomy, cement augmentation in the anterior
column and posterior fixation with spinal cord decompression.
DESCRIPTION OF PROCEDURE:
The patient was brought into the operating room, where time-out
protocol was observed with the patient awake. The patient did
received preoperative antibiotics in a timely fashion. General
endotracheal anesthesia was induced. The patient was rolled into
the prone position on the Jackson table and all potential
pressure points including nervous structures and eyes were
carefully checked and protected. The patient's back was prepped
and draped in sterile fashion. A skin blade was used to make an
appropriate-length skin incision centered over T12 counting from
the sacrum using spinal needles. This was confirmed by Dr.
Steven Spisak in the room, my assistant.
Standard posterior approach to the thoracic spine was carried
out, dissecting the tips of the transverse processes of T11, T12
and L1. Pedicle screws were placed at T11 and L1 using standard
anatomic starting point. A high-speed bur was used to perform
corticotomy. A Lenke probe was used to cannulate the pedicle. A
ball-tip probe was used to feel the hole. There was some
breakout on the left at L1, so this one was placed later, when we
were directly visualizing the pedicle. After all three screws
were placed, they were checked under lateral fluoroscopy and
stimulated without complication.
The high-power two-headed microscope was brought in the field and
used for the remainder of the procedure. We took down the
inferior T11, the entire T12 and superior L1 spinous processes.
The high-speed bur was then used to thin the inferior T11, the
entire T12 and the superior L1 laminae. Thinned laminar bone was
then removed with a Kerrison. Thinned facet bone around T12 was
removed with a Kerrison rongeur as well. The right T12 nerve
root was stimulated and there was no evidence of any motor
response. Therefore, this was tied off with two 2-0 silk ties
and divided so that we could mobilize the dural sac without
traction on the spinal cord. We then found a massive amount of
tumor in the vertebral body of T12. This was completely debulked
away from the ventral surface of the spinal cord from cranial to
caudal. Several large semisolid specimens were removed and one
was sent to pathology labeled T12 tumor.
Curets were used to perform a complete extirpation of the tumor.
We did leave any good bone that was present. After complete
tumor resection and checked signals, we then placed a cement
introducer down the left pedicle and cement was introduced into
the vertebral body under direct lateral fluoroscopy. This was
done slowly with direct observation of the spinal cord. There
was no evidence of complication here and excellent fill of the
vertebral deficit was noted with direct visualization. We
allowed the cement to harden, then decorticated the lateral
gutter and irrigated with over three liters via our standard
high-volume, low-pressure irrigation tubing.
We double checked our overall decompression and it was excellent,
especially after removing the ventral tumor. We did take down
the right pedicle and the entire right facet joint complex during
the process of the procedure.
Top-loading rods were applied times two. Top-loading nuts were
applied times four. All four nuts were given a final
torque-limited tightening. Demineralized bone matrix with
allograft was placed in the lateral gutters and 1/2-inch Hemovac
drains times two were applied. One gram of vancomycin was placed
deep to the deep fascia. The deep fascia was closed with #1
Ticron in watertight, figure-of-eight fashion. This was followed
by buried 2-0 subcutaneous, followed by running subcuticular
The wound was steri-stripped and dressed in sterile fashion. The
patient was rolled on his back, extubated and discharged to the
Postanesthesia Care Unit.
There were no complications during this procedure.
My codes are: