Operative report Spinal procedure 3
Operative report 1
Preoperative Diagnosis:
Cervical spondylosis with myelopathy.
Large central disc herniations at C5-C6 and C6-C7 with cephalad and caudal migration of disc fragments.
Cervical spinal canal stenosis.
Cervical radiculopathy.
Postoperative Diagnosis:
Cervical spondylosis with myelopathy.
Large central disc herniations at C5-C6 and C6-C7 with migrated disc fragments.
Cervical spinal canal stenosis.
Cervical radiculopathy.
Procedure Performed:
Anterior cervical discectomy with decompression of the spinal cord and bilateral nerve roots at C5-C6.
Anterior cervical discectomy with decompression of the spinal cord and bilateral nerve roots at C6-C7.
Corepectomy C6
Anterior cervical arthrodesis at C5-C6 and C6-C7.
Insertion of titanium interbody biomechanical cages at C5-C6 and C6-C7.
Anterior cervical plate fixation from C5 through C7.
Indication:The patient presented with progressive neck pain, bilateral upper extremity radiculopathy, gait imbalance, and symptoms of cervical myelopathy. MRI demonstrated large central disc herniations at C5-C6 and C6-C7 with migration of disc fragments behind the C6 vertebral body causing severe spinal cord compression. Conservative treatment including medications, physical therapy, and activity modification failed to provide relief. Surgical decompression and stabilization were recommended. Risks, benefits, alternatives, and potential complications were discussed, and informed consent was obtained.
Description of Procedure:
After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Neuromonitoring was established. The patient was positioned supine with slight cervical extension. The anterior cervical region was prepped and draped in the usual sterile fashion.
Fluoroscopy was used to localize the operative levels. A standard right-sided transverse anterior cervical incision was made. Dissection was carried through the platysma, and the avascular plane between the carotid sheath laterally and the tracheoesophageal complex medially was developed. The prevertebral fascia was incised, and the anterior cervical spine was exposed. A spinal needle and fluoroscopy confirmed the C5-C6 and C6-C7 levels.
Attention was first directed to the C5-C6 disc space. Caspar distraction pins were inserted, and distraction was applied. A complete discectomy was performed using pituitary rongeurs, curettes, and Kerrison punches. Posterior osteophytes were removed, the posterior longitudinal ligament was opened, and decompression of the spinal cord and bilateral neural foramina was completed. Multiple migrated disc fragments extending posterior to the C6 vertebral body were encountered.
To safely remove these migrated fragments, a limited partial resection of the anterior superior portion of the C6 vertebral body was performed using a high-speed burr. This limited vertebral body removal was performed solely to improve visualization and permit complete removal of the migrated disc fragments compressing the spinal cord. No formal corpectomy was performed.
Attention was then directed to the C6-C7 level. A complete discectomy was performed in a similar fashion. Posterior osteophytes and herniated disc material were removed. Bilateral foraminotomies were completed to decompress the exiting nerve roots. Additional migrated disc fragments located posterior to the C6 vertebral body were identified. A small additional portion of the C6 vertebral body was removed to ensure complete decompression and removal of all remaining free disc fragments. Inspection confirmed that the spinal cord and both exiting nerve roots were completely decompressed.
The endplates at C5-C6 and C6-C7 were meticulously prepared for fusion while preserving the subchondral bone. Appropriately sized titanium interbody biomechanical cages packed with bone graft material were inserted into the C5-C6 and C6-C7 intervertebral disc spaces. Fluoroscopy confirmed satisfactory cage position, restoration of disc height, and segmental alignment.
An appropriately sized anterior cervical plate was then positioned spanning C5 through C7. Screws were inserted into C5, C6, and C7 under fluoroscopic guidance. Final fluoroscopic images confirmed satisfactory placement of the titanium cages, anterior cervical plate, screws, and restoration of cervical alignment.
The wound was copiously irrigated with sterile saline. Hemostasis was achieved. A closed-suction drain was placed. The platysma was reapproximated with absorbable sutures, and the skin was closed in a subcuticular fashion. Sterile dressings were applied.
The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.
Findings: Large central disc herniations at C5-C6 and C6-C7 with migrated free disc fragments extending behind the C6 vertebral body producing severe spinal cord compression. Complete decompression of the spinal cord and bilateral nerve roots was achieved. Limited partial removal of the C6 vertebral body was performed solely to facilitate removal of migrated disc fragments and was not a formal corpectomy. Stable anterior cervical fusion was achieved with titanium interbody biomechanical cages and anterior cervical instrumentation.
Implants:
Titanium interbody biomechanical cage at C5-C6.
Titanium interbody biomechanical cage at C6-C7.
Anterior cervical plate spanning C5-C7.
Anterior cervical fixation screws at C5, C6, and C7.
Check your answer
CPT
22551
+22552
22853 ×2
22845
Why 63081 is not coded
The vertebral body was removed only to gain access to migrated disc fragments located behind C6. The removal was incidental to the discectomy and decompression, not a separate decompression procedure.
Furthermore:
The vertebral body was not substantially resected as the primary decompression.
There was no vertebral body defect requiring corpectomy reconstruction.
Fusion was performed using two interbody cages placed into the disc spaces, not a corpectomy cage spanning a vertebral body defect.
Operative report 2
Preoperative Diagnosis:
Herniated nucleus pulposus, C4-C5
Cervical spinal stenosis with spinal cord and nerve root compression
Cervical radiculopathy
Postoperative Diagnosis:
Same as preoperative.
Procedure Performed
Anterior cervical discectomy with decompression of the spinal cord and bilateral nerve roots, C4-C5.
Anterior cervical arthrodesis (fusion), C4-C5.
Insertion of PEEK interbody biomechanical cage, C4-C5.
Placement of anterior cervical plate and screw fixation spanning C4-C5.
Placement of Demineralized Bone Matrix (DBM) within the interbody cage to facilitate fusion.
Indication
The patient presented with persistent neck pain, right upper extremity radiculopathy, and numbness that failed conservative management including medications, physical therapy, and activity modification. MRI of the cervical spine demonstrated a large C4-C5 herniated disc causing significant spinal cord and bilateral nerve root compression. Surgical intervention with anterior cervical discectomy and fusion was recommended. The risks, benefits, alternatives, and potential complications were discussed in detail, and informed consent was obtained.
Procedure
After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. The patient was positioned supine on the operating table with the neck slightly extended. All pressure points were appropriately padded. Intraoperative fluoroscopy was utilized to localize the operative level.
The anterior cervical region was prepped and draped in the usual sterile fashion. A transverse skin incision was made over the C4-C5 level along a natural skin crease. The platysma was divided, and the avascular plane between the sternocleidomastoid muscle and the tracheoesophageal complex was carefully developed. The prevertebral fascia was opened, and fluoroscopy confirmed the C4-C5 disc space.
Caspar distraction pins were inserted into the C4 and C5 vertebral bodies, and gentle distraction was applied. A complete discectomy was performed using pituitary rongeurs, curettes, and Kerrison punches. The cartilaginous endplates were removed while preserving the subchondral bone.
Posterior osteophytes were removed using a high-speed burr and Kerrison rongeurs. The posterior longitudinal ligament was opened, and decompression of the spinal cord and bilateral exiting nerve roots was completed. Herniated disc fragments were removed until no residual compression remained. Bilateral neural foramina were inspected and adequately decompressed.
Following decompression, the endplates were prepared for fusion. An appropriately sized PEEK interbody biomechanical cage was selected. The cage was packed with Demineralized Bone Matrix (DBM) and inserted into the C4-C5 intervertebral disc space under fluoroscopic guidance. Excellent restoration of disc height and segmental alignment was achieved.
An appropriately sized anterior cervical plate was positioned spanning C4 to C5. Screws were inserted into the C4 and C5 vertebral bodies and tightened according to the manufacturer's specifications. Final fluoroscopic imaging confirmed satisfactory placement of the interbody cage, anterior plate, and screws.
The wound was copiously irrigated with sterile saline. Hemostasis was achieved with bipolar electrocautery. The platysma was reapproximated using absorbable sutures, and the skin was closed in layers with absorbable subcuticular sutures. Sterile dressings were applied.
The patient tolerated the procedure well without complications. Sponge, needle, and instrument counts were correct. The patient was awakened from anesthesia and transferred to the recovery room in stable condition.
Findings
Large central C4-C5 herniated disc producing compression of the spinal cord and bilateral exiting nerve roots. Complete decompression was achieved. Stable anterior cervical fusion was accomplished using a PEEK interbody cage filled with Demineralized Bone Matrix (DBM) and anterior cervical plate fixation.
Implants
PEEK interbody biomechanical cage, C4-C5
Anterior cervical plate spanning C4-C5
Anterior cervical screws
Demineralized Bone Matrix (DBM)
Check your answer
22551
22853
22845
Operative report 3
Preoperative Diagnosis:
Herniated nucleus pulposus, C3-C4.
Cervical spinal stenosis with osteophyte formation at C4-C5.
Cervical myeloradiculopathy.
Status post anterior cervical fusion with anterior plate at C5-C6.
Postoperative Diagnosis:
Same as preoperative.
Procedure Performed:
Removal of anterior cervical instrumentation, C5-C6.
Anterior cervical discectomy and decompression, C3-C4.
Anterior cervical discectomy and decompression, C4-C5.
Anterior cervical arthrodesis, C3-C4 and C4-C5.
PEEK interbody cage placement, C3-C4 and C4-C5.
Anterior cervical plating, C3-C5.
Placement of Demineralized Bone Matrix (DBM) and morselized allograft.
Indication:
The patient previously underwent anterior cervical fusion at C5-C6 with anterior cervical plate fixation. The patient developed progressive neck pain, bilateral upper extremity radiculopathy, gait imbalance, and signs of cervical myelopathy. MRI demonstrated a large central disc herniation at C3-C4 and advanced spondylosis with posterior osteophyte formation producing severe spinal canal and bilateral foraminal stenosis at C4-C5. Conservative treatment including medications, physical therapy, and epidural steroid injections failed to provide lasting relief. Revision anterior cervical decompression and fusion was recommended. Risks, benefits, alternatives, and potential complications were discussed with the patient, and informed consent was obtained.
Procedure:
After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) were monitored throughout the procedure. The patient was positioned supine on the operating table with the neck maintained in slight extension using a shoulder roll. All pressure points were carefully padded. Fluoroscopy was utilized to confirm the operative levels before incision.
The previous right-sided transverse cervical incision was reopened. Dissection was carried through the subcutaneous tissues and platysma. Dense postoperative scar tissue was encountered and carefully dissected. The interval between the sternocleidomastoid muscle and the strap muscles was developed. The carotid sheath was protected laterally while the trachea and esophagus were gently retracted medially. The prevertebral fascia was incised, exposing the previous instrumentation.
The existing anterior cervical plate spanning C5-C6 was identified. Fibrous tissue surrounding the plate was removed. The locking mechanism was disengaged, all fixation screws were sequentially removed, and the anterior cervical plate was removed intact without complication. The underlying fusion mass appeared solid.
Attention was directed to the C3-C4 and C4-C5 disc spaces. Operative levels were reconfirmed fluoroscopically. Caspar distraction pins were inserted into the vertebral bodies and gentle distraction was applied.
At C3-C4, a complete anterior cervical discectomy was performed using pituitary rongeurs, curettes, and disc shavers. The cartilaginous endplates were removed while preserving the bony endplates. Posterior osteophytes were removed using a high-speed burr followed by Kerrison rongeurs. The posterior longitudinal ligament was identified and resected. Multiple posterior disc fragments were removed. Bilateral neural foraminotomies were performed until both exiting nerve roots were freely visualized and decompressed. The spinal cord was completely decompressed across the entire width of the canal.
Attention was then directed to C4-C5. A complete discectomy was performed in a similar fashion. Significant uncovertebral hypertrophy and posterior osteophytes producing severe spinal canal narrowing were encountered. These osteophytes were removed with a high-speed burr and Kerrison rongeurs. The posterior longitudinal ligament was excised, and the spinal canal was decompressed. Bilateral foraminotomies were performed with complete decompression of both exiting nerve roots. A nerve hook was passed freely through each neural foramen confirming adequate decompression.
Following decompression, meticulous preparation of both fusion beds was performed. The endplates were decorticated using curettes and rasps until punctate bleeding bone was encountered while preserving structural integrity.
Trial spacers were inserted, and appropriate-sized PEEK interbody cages were selected for C3-C4 and C4-C5. Each cage was packed with Demineralized Bone Matrix (DBM). Additional morselized allograft was packed anteriorly and laterally around the cages to augment fusion. The cages were inserted under fluoroscopic guidance and impacted into final position, restoring disc height, foraminal height, and cervical lordosis.
An appropriately sized anterior cervical plate was selected and positioned spanning C3 through C5. Temporary fixation pins were placed, and fluoroscopy confirmed satisfactory alignment. Definitive variable-angle screws were inserted into the C3, C4, and C5 vertebral bodies. All screws achieved excellent purchase. The locking mechanism was engaged according to the manufacturer's specifications. Final anteroposterior and lateral fluoroscopic images confirmed appropriate placement of the plate, screws, and interbody cages with restoration of cervical alignment.
The wound was irrigated thoroughly with copious sterile saline containing antibiotic solution. Meticulous hemostasis was achieved using bipolar electrocautery and absorbable hemostatic agents. The esophagus and surrounding soft tissues were carefully inspected and found to be intact. A closed-suction drain was placed within the prevertebral space through a separate stab incision.
The platysma was reapproximated with interrupted absorbable sutures. The subcutaneous tissues were closed in layers with absorbable sutures, and the skin was closed using a running subcuticular absorbable suture. Sterile dressings were applied.
The patient tolerated the procedure well without complications. Neuromonitoring remained stable throughout the procedure. Sponge, needle, and instrument counts were correct at the completion of the case. The patient was extubated and transferred to the recovery room in stable condition.
Findings:
Large central C3-C4 disc herniation and severe cervical spondylosis with posterior osteophytes at C4-C5 causing significant spinal cord compression and bilateral foraminal stenosis. Solid prior fusion at C5-C6 with successful removal of anterior instrumentation. Complete decompression of the spinal cord and bilateral exiting nerve roots was achieved. Stable anterior cervical fusion was performed using PEEK interbody cages packed with Demineralized Bone Matrix and morselized allograft with anterior cervical plate fixation spanning C3 through C5.
Implants:
Removal of prior anterior cervical plate and screws, C5-C6.
PEEK interbody cage, C3-C4.
PEEK interbody cage, C4-C5.
Anterior cervical plate, C3-C5.
Variable-angle cervical screws.
Demineralized Bone Matrix (DBM).
Morselized allograft.
Check your answer
22551 – ACDF, first level (C3-C4)
+22552 – Additional ACDF level (C4-C5)
22853 ×2 – PEEK interbody biomechanical devices (one per interspace)
22845 – Anterior cervical plate spanning C3-C5 (3 vertebral segments)
20930 – Morselized allograft
22855 – Removal of prior anterior cervical instrumentation
Operative report 4
Preoperative Diagnosis:
Lumbar spinal canal stenosis, L3-L4 and L4-L5.
Bilateral lumbar foraminal stenosis.
Neurogenic claudication with bilateral lumbar radiculopathy.
Postoperative Diagnosis:
Same as preoperative.
Incidental dural tear with cerebrospinal fluid leak, repaired primarily.
Procedure Performed:
Laminectomy, L3, L4, and L5.
Bilateral medial facetectomies and foraminotomies at L3-L4 and L4-L5.
Excision of hypertrophied ligamentum flavum.
Primary repair of incidental cerebrospinal fluid leak.
Indication:
The patient presented with progressive low back pain, bilateral lower extremity radiculopathy, and neurogenic claudication refractory to conservative management including physical therapy, anti-inflammatory medications, epidural steroid injections, and activity modification. MRI demonstrated severe multilevel lumbar spinal canal stenosis at L3-L4 and L4-L5 with bilateral foraminal narrowing. Surgical decompression was recommended. The risks, benefits, alternatives, and potential complications were discussed with the patient, and informed consent was obtained.
Procedure:
After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Intravenous prophylactic antibiotics were administered. The patient was positioned prone on a Wilson frame with all pressure points adequately padded. Fluoroscopy was utilized to identify and confirm the operative levels.
The lumbar spine was prepped and draped in the standard sterile fashion. A midline incision was made extending from L3 through L5. Dissection was carried through the subcutaneous tissue to the lumbodorsal fascia. The fascia was incised sharply in the midline, and subperiosteal dissection was performed bilaterally to expose the spinous processes, laminae, and medial facet joints of L3, L4, and L5. Self-retaining retractors were placed.
The spinous processes of L3, L4, and the superior portion of L5 were removed using a Leksell rongeur to improve visualization. A high-speed burr was used to thin the laminae, and complete laminectomies of L3, L4, and L5 were performed using Kerrison rongeurs.
Marked hypertrophy of the ligamentum flavum was encountered. The ligamentum flavum was carefully elevated from the underlying dura and completely excised, resulting in significant decompression of the thecal sac.
Attention was then directed to the neural foramina. Bilateral medial facetectomies and generous foraminotomies were performed at L3-L4 and L4-L5 using Kerrison rongeurs. Hypertrophic facet overgrowth and foraminal osteophytes were removed. The exiting L3, L4, and L5 nerve roots were identified and completely decompressed. A nerve hook was passed freely through each neural foramen confirming adequate decompression.
During decompression adjacent to the left L4 nerve root, a small incidental dural tear was identified with cerebrospinal fluid egress. The margins of the dural defect were clearly visualized. The dural laceration was repaired primarily using interrupted 6-0 Prolene sutures under loupe magnification. A collagen dural patch was placed over the repair, followed by application of fibrin sealant. A Valsalva maneuver demonstrated no further cerebrospinal fluid leakage, confirming a watertight repair.
The surgical field was irrigated thoroughly with copious sterile saline. Meticulous hemostasis was achieved using bipolar electrocautery, absorbable hemostatic agents, and bone wax as necessary.
A closed-suction drain was not placed due to the dural repair. The thoracolumbar fascia was closed with interrupted heavy absorbable sutures. The subcutaneous tissues were closed in multiple layers with absorbable sutures, and the skin was closed with staples. Sterile dressings were applied.
The patient tolerated the procedure well. Sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was awakened from anesthesia and transferred to the recovery room in stable condition.
Findings:
Severe lumbar spinal canal stenosis at L3-L4 and L4-L5 secondary to hypertrophic ligamentum flavum, facet hypertrophy, and degenerative changes causing compression of the thecal sac and bilateral exiting nerve roots. Complete decompression was achieved following multilevel laminectomy, ligamentum flavum excision, and bilateral foraminotomies. A small incidental cerebrospinal fluid leak occurred intraoperatively and was successfully repaired with primary suture repair reinforced with collagen dural patch and fibrin sealant.
Implants:
Collagen dural patch.
Fibrin sealant.
Check your answer
63047 – Laminectomy, facetectomy, and foraminotomy, lumbar, single vertebral segment (first level)
+63048 – Each additional lumbar segment (report as appropriate based on the decompressed vertebral segments)
63707 – Primary repair of incidental dural tear/CSF leak
Operative report 5
Preoperative Diagnosis:
C6-C7 fracture-dislocation.
Cervical spinal instability.
Cervical spinal cord compression secondary to traumatic fracture.
Cervical myelopathy.
Postoperative Diagnosis:
Same as preoperative.
Procedure Performed:
Open reduction of C6-C7 fracture-dislocation through posterior approach.
Posterior cervical arthrodesis, C6-C7.
Posterior nonsegmental instrumentation, C6-C7.
Placement of morselized local autograft and morselized allograft.
Indication:
The patient sustained a traumatic C6-C7 fracture-dislocation resulting in severe cervical instability and spinal cord compression with neurological deficits. Imaging demonstrated disruption of the posterior ligamentous complex with facet dislocation at C6-C7. Because of the unstable nature of the injury, surgical reduction, decompression, stabilization, and fusion were recommended. Risks, benefits, alternatives, and potential complications were discussed with the patient, and informed consent was obtained.
Procedure:
After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Intravenous prophylactic antibiotics were administered. Somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) were monitored throughout the procedure. The patient was carefully positioned prone in a Mayfield head holder with the cervical spine maintained in neutral alignment.
The posterior cervical spine was prepped and draped in the standard sterile fashion. Fluoroscopy was utilized to identify the operative levels. A midline posterior cervical incision was made extending from C5 through T1. Dissection was carried through the subcutaneous tissues to the cervical fascia. Subperiosteal dissection exposed the spinous processes, laminae, lateral masses, and facet joints of C6 and C7.
Significant disruption of the posterior ligamentous structures with traumatic instability at C6-C7 was identified. Fracture fragments and displaced posterior elements were compressing the dorsal aspect of the spinal cord. To facilitate reduction of the fracture-dislocation and adequately decompress the neural elements, a laminectomy of C6 was performed. Fractured laminar fragments, hematoma, and compressive bone fragments were carefully removed. Following decompression, the spinal cord was freely visualized without residual posterior compression.
Attention was then directed to reduction of the fracture-dislocation. Gentle distraction and manipulation were performed under direct visualization. The displaced C6-C7 facet joints were successfully reduced, restoring normal cervical alignment. Fluoroscopic imaging confirmed satisfactory reduction.
The lateral masses of C6 and C7 were prepared for instrumentation. Pilot holes were created using a high-speed burr. The tracts were drilled, palpated, and tapped. Lateral mass screws were inserted bilaterally into C6 and C7. Appropriately contoured rods were secured to the screws bilaterally. Compression across the construct was applied to maintain reduction, and all locking caps were tightened according to the manufacturer's specifications. Final fluoroscopy demonstrated excellent alignment with satisfactory hardware placement.
Attention was then directed to the fusion. The posterior elements, including the lateral masses and facet joints of C6 and C7, were thoroughly decorticated using a high-speed burr until healthy bleeding cancellous bone was encountered. Local autograft obtained during the exposure and laminectomy was morselized and combined with morselized allograft. The graft material was placed over the decorticated fusion bed bilaterally to establish a posterior cervical arthrodesis.
The wound was irrigated thoroughly with copious sterile saline. Meticulous hemostasis was achieved using bipolar electrocautery and absorbable hemostatic agents. A closed-suction drain was placed beneath the fascia.
The cervical fascia was closed with interrupted heavy absorbable sutures. The subcutaneous tissues were closed in layers with absorbable sutures, and the skin was closed with staples. Sterile dressings were applied.
The patient tolerated the procedure well without complications. Sponge, needle, and instrument counts were correct at the completion of the procedure. The patient was transferred to the recovery room in stable condition.
Findings:
Unstable traumatic C6-C7 fracture-dislocation with disruption of the posterior ligamentous complex and compression of the spinal cord by displaced posterior bony fragments. Successful posterior reduction of the fracture-dislocation was achieved. The spinal cord was adequately decompressed following removal of the fractured posterior elements. Stable posterior fixation and arthrodesis were accomplished.
Implants:
Bilateral C6 lateral mass screws.
Bilateral C7 lateral mass screws.
Posterior cervical rods.
Morselized local autograft.
Morselized allograft.
Check your answer
22326
22600
22840
20936
20930
Although the operative report documents a C6 laminectomy, do not report CPT 63001 separately. In this case, the laminectomy was performed to facilitate reduction of the fracture-dislocation and decompress the spinal cord as part of the fracture repair.
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