I will be so grateful for your help!!!
The codes I had in mind:
22633, 22840-50 (do you use a modifier?), 22851, 63047-51 (L5-S1 foraminotomy), 38220-59, 20936
PREOPERATIVE DIAGNOSES:
1. L4-L5 dynamic degenerative spondylolisthesis.
2. L4-5 spinal stenosis and bilateral foraminal narrowing with neurogenic claudication
3. Left L5-S1 foraminal stenosis.
POSTOPERATIVE DIAGNOSES:
1. L4-L5 dynamic degenerative spondylolisthesis.
2. L4-5 spinal stenosis and bilateral foraminal narrowing with neurogenic claudication
3. Left L5-S1 foraminal stenosis.
PROCEDURE PERFORMED:
1. Posterior lumbar interbody fusion, L4-L5.
2. Posterolateral fusion, L4-L5.
3. Decompressive laminectomy with partial facetectomies and bilateral
foraminotomies, L4-L5.
4. Non-segmental pedicle screw instrumentation with Orthofix Phoenix
System, bilateral L4 and L5.
5. Placement of prosthetic interbody device Spine Wave StaXx-D system, 22mm x 9mm x12mm x 8degrees lordotic
mm.
6. Use of bone graft substitute, chronOs.
7. Use of bone marrow aspirate through a separate incision.
8. Use of local bone autograft.
9. Left L5-S1 foraminotomy.
IMPLANTS INSERTED
1. Interbody device Spine Wave StaXx-D system, 22mm x 9mm x12mm x 8degrees lordotic.
2. Orthofix Phoenix Screws 6.5mm x 45 mm bilateral L4 pedicles, 6.5mm x 40mm bilateral L5 pedicles.
The operative level was identified prior to making an incision with the use of biplanar fluoroscopy over the L4-L5 as well as the L5-S1 levels. A central midline incision was performed over the L4 and L5 levels after performing a formal preoperative time-out. The skin was then injected with 30 mL of 0.25% bupivacaine with epinephrine. Dissection was carried down to the lumbosacral fascia using Bovie cauterization. The lumbosacral fascia was incised in line with the skin incision. Subperiosteal dissection was carried down to the spinous processes at the L4-L5 level and carried out laterally past the lamina and facets. The transverse processes of L4 and L5 were then well exposed. Following full exposure, attention was placed towards placement of pedicle screws with fluoroscopic guidance. The pedicle screw starting points were located using fluoroscopy in the lateral view and also anatomical landmarks. The pedicles were prepared for screw insertion using sequentially a burr for a starting hole, pedicle probe, ball-tipped feeler, 5.5 tap, and again a ball tip feeler. No pedicle breach was detected with the feeler, in the prepared pedicles. Pedicle screws were placed in bilateral L4 and L5 pedicles using 6.5 mm screws from the Orthofix Phoenix System. The size of the screws was 6.5 x 45 mm bilateral L4, and 6.5 x 40 mm bilateral L5. The we started with the laminectomy. Using a rongeur, the spinous processes of L4 as well as the superior aspect of L5 were excised. Using Kerrison rongeurs, a complete laminectomy of L4 was performed. The cephalad edge of the L5 lamina was also excised and undercut until there was no more pressure on the dural sac and it was mobile for more than 1.5 cm without any stress. The total extent of the decompression was from the inferior aspect of the L5 pedicles, to the middle of the L4 pedicles, comfirmed with fluroscopy. A partial facetectomy of the bilateral L4-5 facets was performed to fully decompress the lateral recesseses. Then, a 2 mm Kerrison rongeur was used to perform bilateral foraminotomies at the L4-L5 level, decompressing the exiting L4 nerves. The Woodson elevator was able
to be placed freely without any resistance into the foramens. The transversing L5 nerve roots appeared to be completely free in the lateral recess. Next, attention was placed towards the interbody fusion. Beginning at the L4-L5 on the patient's left side, a near complete facetectomy was then performed, gaining access to the disk space. An annulotomy was performed using a 15 blade and a complete and thorough diskectomy was performed using a series of pituitary rongeurs, curettes and Kerrison rongeurs. Satisfied, a complete and thorough diskectomy was performed, this patient was then packed with autograft bone, and chronOs allograft mixed with vancomycin powder. A Spine Wave StaXx-D cage, 22 mm x9 mm x 8 degree lordotic was placed in the disk space and elevated to 12 mm. Fluoroscopic images AP and lateral assured a good position of the cage.
We also did follow the L5 nerve roots bilaterally out through the L5-S1
foramen and we performed a full decompression of the L5-S1 foramen,
especially on the left side, where there was impingement of the left L5
nerve root on the MRI. Again, the Woodson elevator was able to be placed
easily through the foramen of L5-S1 bilaterally without any resistance.
We then completed the posterolateral fusion. A high-speed burr was used to decorticate the posterolateral elements bilaterally from L4 down to L5. Then, a mixture of the chronOs allograft, autograft lamina bone, BMA, and vancomycin was placed in the posterolateral gutters in preparation for the fusion. Prior to placement of the mixture we irrigated with > 2L of NS. The appropriate sized rod, 40 mm, was bent to the appropriate lordosis and then the tulip heads were placed and the set screws and the rod was fixed securely to the tulip heads and screws. They were final tightened in the usual fashion after placing some compression on the screws. At this point, hemostasis was obtained using bipolar cauterization, and Floseal. Final AP and lateral fluoroscopic images were obtained to confirm proper position of all implants.
Combined posterolateral/posterior fusion...
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