Spine surgery

Hi fellow coders - -

I am new at spine coding. Just when I thought I had a pretty good grasp on coding, I get this one - - - If anyone can help it will be greatly appreciated. Thank you so very much in advance.

Springo

POSTOPERATIVE DIAGNOSES:
1. Status post L3 to L5 laminectomy 02/25/2015 with large fluid collection
and recurrent radiculopathy.
2. Left inferior facet fracture of L3.
3. Postoperative dural tear from fracture.
4. Deep fascial dehiscence.

SURGERIES PERFORMED:
1. Irrigation and debridement of laminectomy wound.
2. Repair of postoperative dual tear.
3. Partial facetectomy, left L3-L4 facet with excision of inferior
articular process of left L3.
4. Bone marrow aspiration via separate incision.
5. Use of intraoperative vancomycin.

HISTORY AND INDICATIONS: The patient is a pleasant 73-year-old male who underwent laminectomy back in 10/25/2015. He initially experienced a great result from the surgery with relief of his claudication and radiculopathy,
but then on postop day 5, he noticed an onset of increased back pain with no clear inciting event. Over time he also noticed that his incision appeared to be bulging more. He did have dressing changes by VNA initially on postop day #5 at home the incision was noted normal. Then I saw him about 2 weeks after his surgery, at that point having return of left lower extremity radiculopathy to a lesser extent than before, but his incision did seem swollen with probable fluctuance under it. There were no signs of infection and all his inflammatory markers remained normal. I did have a repeat clinical evaluation with the patient, about 1 week afterward where the fluctuation in his back appeared to be bigger and patient had developed headaches over time. He did have an MRI performed at Milford Emergency Department where it showed a very large 14 cm fluid collection extending from the dura as well as the fracture of the left inferior articular
processes of L3. At this time, the decision was made to return the patient to the OR due to the fracture and likely dural tear with compression in his neurovascularly structures. We had assured decision-making informed choices consent in clinic and patient signed informed consent.

DETAILS OF THE PROCEDURE: The patient was seen in the preoperative holding area. The back was marked in the usual fashion. He had 2 grams of IV Ancef prior to the procedure for antibiotic prophylaxis per protocol. He had compression stockings and Venodyne boots in place for DVT prophylaxis. He was then transferred to the operating room, placed under general endotracheal anesthesia without complication. He was transferred into the prone position on a Jackson spinal table with the Wilson frame placed, to allow for gentle lumbar flexion. All bony prominences were well padded.
Arms were placed and well padded on arm boards. The lumbar area was prepped and draped in the usual sterile fashion. A formal timeout was performed prior to the beginning of the procedure. The operative level of the L3 to L5 interspaces was confirmed with the lateral x-ray. We also had the previous incision. The skin was then incised sharply. At the site of the previous incision and clear fluid started draining from the incision. There was very small amount of hematoma present; this was suctioned. Then, we went down through the subcutaneous tissue, excise all the old stitches and we saw a large dehiscence of his lumbosacral fascia. The lumbosacral fascia was then carefully opened up and deep retractors were placed. All the old #1 Vicryl sutures were removed. At this time, we performed irrigation with 1 L of lactated Ringers. Following evacuation of old hematoma as well as abundant clear fluid suggestive of CSF, it was
noted that the left inferior articular process of L3 was completely lose and fractured. We also saw a lot of clear fluid coming from underneath the fracture. The fragment was carefully excised and at that point we identified 4 different
dural tears at the site of the fracture. We slowly proceeded to repair all the dural tears using a 6-0 Gore-Tex suture. The repairs were all repaired primarily. We performed Valsalva maneuver after that and there was no more CSF fluid coming out. Then, we performed a small facetectomy on the left L3-L4 facet to remove any fracture edges. The inferior
articular process of L3 was completely removed because it was loose with very little attachments. It was putting pressure on the left sided neurovascular structures. Following a great watertight repair, we performed another irrigation using more than 2 liters of normal saline impregnated with bacitracin. Then, we inspected around and there was no CSF leaking and the incision was completely dry and no active bleeding. At this time, using a Jamshidi needle through a separate incision we obtained bone marrow aspirate. We then proceeded to place a Duragen patch on top of the dura again inspecting and seeing no active CSF leak. Then, the blood was mixed with FloSeal to create a blood
patch over the Duragen patch. Following this, a very thin layer of Tisseel was placed to complete the patch over the repair. Again, we inspected around, there was no active bleeding, no CSF. At this point, we placed 1 g of vancomycin powder intraoperatively in the wound. We then proceeded with the closure using a #1 PDS in an interrupted and running fashion. The lumbosacral fascia was closed inspecting for any defects; we did not see any. Then, we turned our attention to closing the subcutaneous tissue with 2-0 PDS. Then, a running nylon was used to close the skin. Dry sterile
dressings were placed on top of the incision. Following this, the patient then was gently transferred back to the supine position on the hospital bed. He was extubated without complication, was moving all extremities. He was later transferred to the recovery in stable condition. I was the primary surgeon on record and I was present for the entirety of the case. There were no complications during the case. All sponge counts were correct x 2 at the end of the case including needle, cottonoid.

Spine surgery