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Operative report Spinal procedure 4

Writer: Medycoding Expert
Medycoding Expert
Jul 26
9 min read


Operative report 1



Preoperative Diagnosis:

  • Acute osteoporotic compression fracture of L2.

  • Severe low back pain refractory to conservative treatment.


Postoperative Diagnosis:

  • Same as preoperative.


Procedure Performed:

  • Percutaneous vertebroplasty, L2.


Indication:

The patient is a 72-year-old individual with persistent severe low back pain secondary to an acute osteoporotic compression fracture of the L2 vertebral body. Conservative management, including analgesics, bracing, and activity modification, failed to provide adequate pain relief. MRI demonstrated persistent bone marrow edema within the L2 vertebral body consistent with an acute compression fracture. Percutaneous vertebroplasty was recommended to stabilize the fracture and relieve pain. The risks, benefits, alternatives, and potential complications, including cement leakage, neurologic injury, infection, pulmonary embolism, and adjacent level fracture, were discussed with the patient. Informed consent was obtained.


Procedure:

After informed consent was obtained, the patient was brought to the operating suite and placed prone on a radiolucent table. Intravenous antibiotics were administered prior to the procedure. Monitored anesthesia care with local anesthetic infiltration was utilized. The thoracolumbar region was prepped and draped in the standard sterile fashion.


Using biplanar fluoroscopic guidance, the L2 vertebral body was identified and confirmed. The skin and subcutaneous tissues overlying the bilateral pedicles were infiltrated with 1% lidocaine followed by 0.25% bupivacaine.

Small stab incisions were made over the pedicle entry sites. Vertebroplasty needles were advanced percutaneously through the pedicles into the anterior third of the L2 vertebral body under continuous anteroposterior and lateral fluoroscopic guidance. Needle placement was confirmed in satisfactory position.


Polymethylmethacrylate (PMMA) bone cement was prepared to the appropriate viscosity. Under continuous fluoroscopic monitoring, PMMA cement was slowly injected into the L2 vertebral body through the vertebroplasty needles. Cement distribution was observed filling the trabecular bone throughout the fractured vertebral body with satisfactory interdigitation. There was no evidence of posterior cement extravasation, epidural leakage, venous leakage, or cement migration.


After adequate filling of the vertebral body, cement injection was discontinued. The cement was allowed to polymerize completely before removal of the vertebroplasty needles. Final fluoroscopic images demonstrated satisfactory cement distribution and stable fracture augmentation.

The skin was cleansed, and the small stab incisions were closed with adhesive strips. Sterile dressings were applied.

The patient tolerated the procedure well without complications and was transferred to the recovery area in stable condition.


Findings:

Acute osteoporotic compression fracture involving the L2 vertebral body. Successful percutaneous vertebroplasty was performed with satisfactory PMMA cement filling and stabilization of the fractured vertebra. No cement leakage or procedural complications were identified.

Implants:

  • Polymethylmethacrylate (PMMA) bone cement.


CPT

22511 – Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, lumbar.





Operative report 2



Preoperative Diagnosis:

  • Lumbar extradural intraspinal tumor at L2.

  • Lumbar spinal cord and cauda equina compression.

  • Mechanical low back pain.


Postoperative Diagnosis:

  • Same as preoperative.


Procedure Performed:

  • Excision of extradural intraspinal lesion, lumbar.

  • L2 corpectomy.

  • Anterior column reconstruction with intervertebral biomechanical cage.

  • Microsurgical decompression utilizing operating microscope.

  • Posterior lumbar arthrodesis, L1-L3.

  • Posterior segmental pedicle screw instrumentation, L1-L3.

  • Placement of morselized local autograft and cancellous allograft.


Indication:

The patient is a 61-year-old individual with progressive low back pain, bilateral lower extremity weakness, and neurogenic symptoms secondary to a large extradural lumbar spinal lesion involving the L2 vertebral body with significant compression of the thecal sac and cauda equina. MRI demonstrated destruction of the L2 vertebral body with extension into the spinal canal. Surgical excision with corpectomy, decompression, spinal reconstruction, and stabilization 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. Intravenous prophylactic antibiotics were administered. Somatosensory and motor evoked potential monitoring was utilized throughout the procedure. The patient was positioned prone on a radiolucent spinal table. The thoracolumbar region was prepped and draped in the usual sterile fashion.

Fluoroscopy was utilized to identify the operative levels. A midline incision extending from L1 through L3 was performed. Subperiosteal dissection exposed the posterior elements including the laminae, facet joints, transverse processes, and pedicles.


Pedicle screws were inserted bilaterally into L1 and L3 under fluoroscopic guidance. Temporary rods were placed to maintain spinal stability during the corpectomy.

The operating microscope was brought into the operative field and utilized throughout the decompression and tumor excision. Under microsurgical magnification, a laminectomy of L2 was performed to expose the thecal sac and cauda equina. The extradural lesion was identified compressing the neural elements circumferentially. Careful microsurgical dissection was carried out using microsurgical instruments to separate the lesion from the dura and adjacent nerve roots. The lesion was excised in a piecemeal fashion until complete removal was achieved. The dura remained intact without cerebrospinal fluid leakage.


Attention was then directed to the L2 vertebral body. A complete L2 corpectomy was performed. The remaining vertebral body was removed using osteotomes, curettes, pituitary rongeurs, and a high-speed drill. The adjacent superior and inferior endplates were carefully prepared while preserving their structural integrity. Following removal of the vertebral body, the spinal canal was inspected, confirming complete decompression of the thecal sac and exiting nerve roots.


The corpectomy defect was measured, and an expandable intervertebral biomechanical cage packed with morselized local autograft and cancellous allograft was inserted into the defect under fluoroscopic guidance. The cage was expanded until satisfactory restoration of vertebral body height and sagittal alignment was achieved.

Definitive rods were then secured to the pedicle screws. Compression across the construct was applied, and all locking caps were tightened according to the manufacturer's specifications. Final fluoroscopic images confirmed satisfactory placement of the instrumentation and cage with excellent spinal alignment.

The transverse processes of L1 and L3 were decorticated. Additional morselized local autograft and cancellous allograft were placed over the posterolateral fusion bed to complete the arthrodesis.


The wound was irrigated thoroughly with sterile saline. Meticulous hemostasis was achieved using bipolar electrocautery and absorbable hemostatic agents. A closed-suction drain was placed in the wound.

The fascia was closed with interrupted heavy absorbable sutures. The subcutaneous tissue was 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:

Large extradural lumbar spinal lesion involving the L2 vertebral body with significant compression of the thecal sac and cauda equina. Complete microsurgical excision of the extradural lesion and L2 corpectomy were successfully performed. Stable reconstruction was achieved using an expandable intervertebral biomechanical cage and posterior pedicle screw instrumentation.


Implants:

  • Expandable intervertebral biomechanical cage.

  • Bilateral pedicle screws at L1 and L3.

  • Titanium rods.

  • Morselized local autograft.

  • Cancellous allograft.





Operative report 3



Preoperative Diagnosis:

  • Acute osteoporotic compression fracture of L1.

  • Progressive vertebral body collapse with focal kyphotic deformity.

  • Severe mechanical back pain refractory to conservative treatment.


Postoperative Diagnosis:

  • Same as preoperative.


Procedure Performed:

  • Percutaneous balloon kyphoplasty, L1.


Indication:

The patient is a 74-year-old individual with persistent severe back pain secondary to an acute osteoporotic compression fracture involving the L1 vertebral body. Despite treatment with analgesics, activity modification, bracing, and osteoporosis management, the patient continued to experience debilitating pain and progressive vertebral height loss. MRI demonstrated persistent bone marrow edema consistent with an acute compression fracture. Because of continued symptoms and progressive kyphotic deformity, percutaneous balloon kyphoplasty was recommended. Risks, benefits, alternatives, and potential complications, including cement leakage, infection, neurologic injury, pulmonary embolism, adjacent level fracture, and failure of pain relief, were discussed with the patient. Informed consent was obtained.


Procedure:

After informed consent was obtained, the patient was brought to the operating room and placed prone on a radiolucent table. Monitored anesthesia care with local anesthetic infiltration was administered. Intravenous prophylactic antibiotics were given prior to the procedure. The thoracolumbar region was prepped and draped in the usual sterile fashion.

Using biplanar fluoroscopic guidance, the L1 vertebral body was identified and confirmed. The skin and subcutaneous tissues overlying the bilateral pedicles were infiltrated with 1% lidocaine followed by 0.25% bupivacaine.

Small stab incisions were made bilaterally. Working cannulas were advanced through the pedicles into the posterior aspect of the L1 vertebral body under continuous fluoroscopic guidance. Proper positioning of the cannulas was confirmed on both anteroposterior and lateral fluoroscopic images.


Kyphoplasty balloons were introduced through each working cannula into the vertebral body. Under fluoroscopic visualization, the balloons were gradually inflated, creating bilateral cavities within the vertebral body while restoring vertebral body height and correcting the focal kyphotic deformity. Adequate reduction was achieved without cortical breach. The balloons were subsequently deflated and removed.

Polymethylmethacrylate (PMMA) bone cement was prepared to the appropriate viscosity. Under continuous fluoroscopic monitoring, the cement was slowly injected into the cavities created by the balloons until satisfactory filling of the vertebral body was achieved. Cement distribution was uniform throughout the fracture site with excellent interdigitation. No posterior cement extravasation, epidural leakage, venous leakage, or cement migration was identified.

The cement was allowed to polymerize completely before removal of the working cannulas. Final fluoroscopic imaging demonstrated satisfactory restoration of vertebral body height, improved sagittal alignment, and excellent cement placement within the L1 vertebral body.

The skin incisions were irrigated and closed with adhesive strips. Sterile dressings were applied.

The patient tolerated the procedure well without complications and was transferred to the recovery area in stable condition.


Findings:

Acute osteoporotic compression fracture of the L1 vertebral body with loss of anterior vertebral height and focal kyphotic deformity. Successful balloon kyphoplasty restored vertebral body height and stabilized the fracture with satisfactory PMMA cement augmentation. No cement leakage or procedural complications were encountered.

Implants:

  • Polymethylmethacrylate (PMMA) bone cement.


22514 – Percutaneous vertebral augmentation, including cavity creation (e.g., balloon kyphoplasty), using mechanical device, 1 lumbar vertebral body, unilateral or bilateral cannulation.





Operative report 4



Preoperative Diagnosis:

  • C5 burst fracture with severe vertebral body collapse.

  • Cervical spinal cord compression secondary to retropulsed fracture fragments.

  • Cervical instability.

  • Cervical myelopathy.


Postoperative Diagnosis:

  • Same as preoperative.


Procedure Performed:

  • C5 anterior cervical corpectomy with decompression of the spinal cord.

  • Anterior cervical arthrodesis, C4-C6.

  • Insertion of expandable intervertebral biomechanical cage spanning C4-C6.

  • Anterior cervical plate fixation, C4-C6.

  • Placement of morselized local autograft and demineralized bone matrix (DBM).


Indication:

The patient is a 56-year-old individual who sustained a traumatic burst fracture of the C5 vertebral body resulting in severe collapse of the vertebral body with retropulsed bone fragments causing marked spinal cord compression and cervical instability. MRI demonstrated significant cervical canal compromise with evidence of spinal cord compression. Surgical decompression, reconstruction, and stabilization 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. Somatosensory and motor evoked potential monitoring were established. Intravenous prophylactic antibiotics were administered. The patient was positioned supine with the neck maintained in neutral alignment. The anterior cervical region was prepped and draped in the usual sterile fashion.


Fluoroscopy was utilized to identify the operative levels. A standard left-sided transverse anterior cervical incision was made. Dissection was carried through the platysma, and the avascular plane between the sternocleidomastoid muscle and carotid sheath laterally and the trachea and esophagus medially was developed. Self-retaining retractors were placed, and fluoroscopy confirmed exposure of C4 through C6.

Complete discectomies were performed at C4-C5 and C5-C6. The cartilaginous endplates were removed while preserving the bony endplates.


Attention was then directed to the C5 vertebral body. Using a high-speed drill, Kerrison rongeurs, curettes, and pituitary rongeurs, a complete C5 corpectomy was performed. The collapsed vertebral body and retropulsed fracture fragments were carefully removed. The posterior vertebral wall was excised, and the posterior longitudinal ligament was opened. Multiple retropulsed bony fragments compressing the spinal cord were meticulously removed until complete decompression of the spinal cord and bilateral exiting nerve roots was achieved. The dura was freely visualized without residual compression.


The corpectomy defect was measured, and an expandable titanium intervertebral biomechanical cage packed with morselized local autograft and demineralized bone matrix was inserted between the inferior endplate of C4 and the superior endplate of C6. The cage was expanded under fluoroscopic guidance until appropriate restoration of vertebral body height, cervical lordosis, and anterior column stability was achieved.

An appropriately sized anterior cervical plate was then applied spanning C4 through C6. Screws were inserted into C4 and C6 under fluoroscopic guidance. Final tightening was completed according to the manufacturer's specifications. Final fluoroscopic images confirmed satisfactory alignment and appropriate positioning of the cage, plate, and screws.


The wound was copiously irrigated with sterile saline. Meticulous hemostasis was achieved. A closed-suction drain was placed. The platysma was closed with interrupted absorbable sutures, the subcutaneous tissue was reapproximated, and the skin was closed in a subcuticular fashion. 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 awakened from anesthesia and transferred to the recovery room in stable condition.


Findings:

Severely comminuted C5 burst fracture with collapse of the vertebral body and retropulsed bone fragments producing significant spinal cord compression. Complete decompression of the spinal cord was achieved following C5 corpectomy. Stable anterior reconstruction was accomplished using an expandable titanium cage and anterior cervical plate fixation.


Implants:

  • Expandable titanium intervertebral biomechanical cage.

  • Anterior cervical plate (C4-C6).

  • Cervical fixation screws.

  • Morselized local autograft.

  • Demineralized bone matrix (DBM).




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