Operative report Spinal procedure 3

Operative report 1

Preoperative Diagnosis

1. Degenerative thoracolumbar scoliosis.

2. Lumbar spinal stenosis.

3. Post-laminectomy syndrome.

4. Lumbar radiculopathy.

5. Multilevel lumbar degenerative disc disease with segmental instability involving L3-L4, L4-L5, and L5-S1.

Postoperative Diagnosis

1. Degenerative thoracolumbar scoliosis.

2. Lumbar spinal stenosis.

3. Post-laminectomy syndrome.

4. Lumbar radiculopathy.

5. Multilevel lumbar degenerative disc disease with segmental instability involving L3-L4, L4-L5, and L5-S1.

Procedure Performed :

1. Posterior/posterolateral arthrodesis from T10 through S1.

2. Posterior lumbar interbody arthrodesis (PLIF) at L3-L4, L4-L5, and L5-S1.

3. Placement of interbody biomechanical cages at L3-L4, L4-L5, and L5-S1.

4. Posterior segmental pedicle screw instrumentation from T10 through S1.

5. Placement of morselized local autograft and cancellous allograft.

Indication

The patient is a 40-year-old individual with progressive thoracolumbar spinal deformity secondary to degenerative scoliosis, multilevel lumbar spinal stenosis, post-laminectomy syndrome, chronic lumbar radiculopathy, and advanced degenerative disc disease. The patient had persistent disabling back pain, lower extremity pain, progressive deformity, and functional decline despite prolonged conservative management including medications, physical therapy, epidural injections, and activity modification. Radiographic studies demonstrated multilevel instability with degenerative scoliosis requiring long-segment stabilization. Surgical reconstruction with posterior spinal fusion and selective lumbar interbody fusion was recommended.

Description of the Procedure

After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), and free-running electromyography (EMG) were established for continuous neuromonitoring. Intravenous prophylactic antibiotics were administered prior to incision. The patient was positioned prone on a radiolucent Jackson spinal table with the abdomen free to reduce epidural venous pressure. All pressure points were carefully padded.

Using fluoroscopic guidance, the operative levels from T10 through S1 were identified and marked. The thoracolumbar spine was prepped and draped in the usual sterile fashion. A long midline posterior incision extending from T10 to S1 was made. Dissection was carried sharply through the subcutaneous tissue to the thoracolumbar fascia. The fascia was divided in the midline, and extensive bilateral subperiosteal dissection was performed using Cobb elevators and electrocautery to expose the spinous processes, laminae, facet joints, pars interarticularis, transverse processes, and sacral ala from T10 through S1. Self-retaining retractors were placed to maintain exposure.

Facet joint capsules were excised throughout the operative field. Significant scar tissue from the previous lumbar laminectomy was encountered and carefully dissected away from the underlying dura using microsurgical technique without dural injury. Fluoroscopy confirmed all operative levels.

Pedicle screw entry points were identified using standard anatomical landmarks. A high-speed burr was used to create each pedicle entry site. Pedicle probes were advanced into each pedicle under fluoroscopic guidance, and each tract was palpated with a ball-tipped probe to verify intact cortical walls. The pedicles were sequentially tapped, and appropriately sized pedicle screws were inserted bilaterally at T10, T11, T12, L1, L2, L3, L4, L5, and S1. Screw position was verified fluoroscopically.

Attention was first directed to the L3-L4 interspace. Bilateral facetectomies and limited laminotomies were performed to obtain safe access to the disc space. The exiting and traversing nerve roots were identified and protected throughout the procedure. A posterior annulotomy was performed followed by complete discectomy utilizing pituitary rongeurs, curettes, Kerrison rongeurs, and sequential disc shavers. Cartilaginous endplates were meticulously prepared while preserving the subchondral bone. Trial spacers were inserted to determine appropriate cage size and lordotic angle. The anterior disc space was packed with morselized local autograft mixed with cancellous allograft. An appropriately sized lordotic interbody cage packed with graft material was inserted under fluoroscopic guidance with restoration of disc height and segmental alignment.

An identical posterior lumbar interbody fusion was then performed at L4-L5. Complete discectomy and endplate preparation were carried out. Following sequential trialing, an appropriately sized lordotic interbody cage packed with graft material was inserted under fluoroscopic guidance.

Attention was subsequently directed to the L5-S1 interspace. Bilateral facetectomies were completed to improve visualization. A complete discectomy was performed and the cartilaginous endplates were meticulously prepared. Trial implants were utilized to determine optimal cage dimensions. The disc space was packed with graft material followed by insertion of a third lordotic interbody cage under fluoroscopic guidance. Final fluoroscopic imaging confirmed satisfactory position of all three interbody devices.

Appropriately contoured titanium rods were fashioned to restore physiologic thoracolumbar sagittal alignment and were sequentially seated into the pedicle screw heads bilaterally. Rod reduction instruments were utilized as necessary. Sequential compression, distraction, derotation, and in-situ rod contouring maneuvers were performed to correct the patient's coronal scoliosis, restore lumbar lordosis, and optimize global sagittal balance. Final locking caps were applied and tightened with the manufacturer's calibrated torque-limiting device.

Attention was then directed to the posterolateral arthrodesis. The transverse processes, residual facet joints, pars interarticularis, and sacral ala from T10 through S1 were extensively decorticated using a high-speed burr until healthy bleeding cancellous bone was encountered. Morselized local autograft harvested during the procedure was combined with cancellous allograft and placed generously within the bilateral posterolateral gutters extending continuously from T10 through S1 to establish a robust posterolateral fusion mass.

Final anteroposterior and lateral fluoroscopic images demonstrated satisfactory correction of the thoracolumbar deformity with restoration of coronal and sagittal alignment. Pedicle screws, rods, and interbody cages were all confirmed to be in satisfactory position.

The wound was copiously irrigated with pulsatile antibiotic-containing saline solution. Meticulous hemostasis was achieved using bipolar electrocautery, bone wax, and absorbable hemostatic agents. Two closed-suction drains were placed in the subfascial space.

The thoracolumbar fascia was reapproximated with interrupted heavy absorbable sutures. The subcutaneous tissue was closed in multiple layers using absorbable sutures. Skin closure was performed with staples, and sterile dressings were applied.

The patient tolerated the procedure well without intraoperative complications. Neuromonitoring remained stable throughout the procedure. Sponge, needle, and instrument counts were correct at the conclusion of the case. The patient was awakened from anesthesia and transferred to the recovery room in stable condition.

Findings

Severe multilevel degenerative thoracolumbar scoliosis with post-laminectomy changes, advanced lumbar degenerative disc disease at L3-L4, L4-L5, and L5-S1, facet arthropathy, lumbar spinal stenosis, and multilevel segmental instability. Excellent deformity correction was achieved with stable posterior segmental instrumentation, successful three-level posterior lumbar interbody fusion, and continuous posterolateral fusion from T10 through S1.

Implants

* Pedicle screws placed bilaterally from T10 through S1.

* Bilateral titanium rods.

* Three lordotic interbody biomechanical cages at L3-L4, L4-L5, and L5-S1.

* Morselized local autograft bone.

* Cancellous allograft bone.

Check your answer

CPT

22610

+22614 ×2

22633

+22634 ×2

22844

22853 ×3

20930

20936

Operative report 2

Preoperative Diagnosis

1. Fixed lumbar kyphotic deformity.

2. Degenerative lumbar scoliosis.

3. Sagittal spinal imbalance.

4. Lumbar spinal stenosis at L4-L5.

Postoperative Diagnosis

Same.

Procedure Performed

1. Posterior lumbar spinal osteotomy (Smith-Petersen/Ponte type) at L3 for correction of fixed sagittal deformity.

2. Posterior/posterolateral lumbar arthrodesis L2-L4.

3. Posterior segmental pedicle screw instrumentation L2-L4.

4. Separate decompressive lumbar laminectomy with bilateral foraminotomies at L4-L5.

5. Placement of morselized local autograft and cancellous allograft.

Indication

The patient presented with progressive mechanical low back pain, neurogenic claudication, lumbar radiculopathy, and a rigid lumbar kyphotic deformity associated with degenerative scoliosis and sagittal imbalance. Imaging demonstrated a fixed deformity centered at L3 requiring corrective osteotomy. In addition, severe lumbar spinal stenosis producing neural compression was identified at the adjacent L4-L5 level. Following failure of prolonged conservative management, operative correction was recommended.

Description of the Procedure

Following induction of general anesthesia, neuromonitoring was established. The patient was positioned prone on a radiolucent Jackson spinal table. Intravenous antibiotics were administered, and the lumbar spine was prepped and draped in the usual sterile fashion.

A midline posterior incision extending from L2 through L5 was made. Bilateral subperiosteal exposure of the posterior elements was performed, exposing the spinous processes, laminae, facet joints, pars interarticularis, and transverse processes.

Pedicle screws were inserted bilaterally at L2, L3, and L4 under fluoroscopic guidance after standard pedicle preparation.

Attention was directed to the L3 vertebral segment where the fixed deformity was located. A posterior column osteotomy was performed by resecting the spinous process, lamina, ligamentum flavum, pars interarticularis, and bilateral facet joints. This created a controlled posterior bony gap allowing mobilization of the rigid deformity. The osteotomy was performed specifically to restore lumbar lordosis and improve global sagittal alignment. The thecal sac and exiting nerve roots were carefully protected throughout the procedure.

After completion of the osteotomy, precontoured rods were secured to the pedicle screw construct. Sequential compression was applied across the osteotomy site, resulting in controlled closure of the posterior column osteotomy and restoration of physiologic lumbar lordosis. Final construct alignment was confirmed fluoroscopically.

Attention was then directed to the **separate L4-L5 interspace**, where severe lumbar spinal stenosis was present. A complete decompressive laminectomy with bilateral medial facetectomies and foraminotomies was performed. The ligamentum flavum was removed, and both traversing and exiting nerve roots were completely decompressed. This decompression was performed at a vertebral level separate from the lumbar osteotomy.

The transverse processes and lateral gutters from L2 through L4 were thoroughly decorticated using a high-speed burr. Morselized local autograft harvested during the procedure was mixed with cancellous allograft and placed over the decorticated posterolateral fusion beds to complete the arthrodesis.

Final fluoroscopic imaging demonstrated satisfactory correction of the lumbar deformity, appropriate hardware placement, restoration of lumbar lordosis, and complete decompression of the L4-L5 spinal canal.

The wound was irrigated, meticulous hemostasis was obtained, a subfascial drain was placed, and the wound was closed in standard layered fashion. The patient tolerated the procedure well without complications.

Findings

Rigid lumbar kyphotic deformity centered at L3 with fixed sagittal imbalance. Severe degenerative spinal stenosis was present at the adjacent L4-L5 level. Excellent correction of lumbar lordosis was achieved following posterior column osteotomy with stable posterior instrumentation.

Implants

* Pedicle screws at L2, L3, and L4.

* Titanium rods.

* Local autograft.

* Cancellous allograft.

Check your answer

CPT -

22214

22612

+22614

22842

63047

20936

20930

Note : Do not report 63047 if the laminectomy/decompression is performed at the same vertebral segment as the osteotomy (L3) because it is inherent in 22214.

63047 is appropriate in this case because the decompression is performed at the adjacent L4-L5 level, which is separate from the osteotomy level.

Operative report 3

Preoperative Diagnosis

1. Fixed cervical kyphotic deformity.

2. Cervical sagittal imbalance.

3. Multilevel cervical spondylosis with autofusion at C5-C6.

Postoperative Diagnosis

Same.

Procedure Performed

1. Anterior cervical spinal osteotomy at C5 (anterior column osteotomy), including discectomy.

2. Anterior cervical arthrodesis at C5-C6.

3. Placement of structural interbody cage.

4. Anterior cervical plate fixation from C5 to C6.

5. Placement of morselized local autograft and structural allograft.

Indication

The patient presented with progressive neck pain, chin-on-chest deformity, impaired horizontal gaze, and progressive cervical sagittal imbalance due to a fixed cervical kyphotic deformity. Imaging demonstrated rigid deformity centered at C5-C6 with marked anterior column contracture and failure of conservative treatment. Surgical correction utilizing an anterior cervical osteotomy was recommended to restore cervical lordosis and sagittal alignment.

Description of the Procedure

Following induction of general endotracheal anesthesia with neuromonitoring, the patient was positioned supine with slight cervical extension. The anterior cervical region was prepped and draped in the usual sterile fashion.

A standard left-sided transverse cervical incision was made. Sharp dissection was carried through the platysma, and the interval between the sternocleidomastoid muscle and strap muscles was developed. The carotid sheath was protected laterally while the trachea and esophagus were gently retracted medially. Fluoroscopy confirmed the operative level.

The prevertebral fascia was incised, exposing the anterior cervical spine at C5-C6. Subperiosteal dissection was performed over the anterior vertebral bodies.

Attention was directed to the fixed deformity. Complete anterior discectomy at C5-C6 was performed using pituitary rongeurs, curettes, and a high-speed burr. The cartilaginous endplates were prepared while preserving the underlying cortical bone.

An anterior column osteotomy was then performed. Residual anterior osteophytes and contracted anterior longitudinal ligament were resected. Controlled wedge resection of the anterior vertebral column was performed using osteotomes and a high-speed burr to mobilize the rigid deformity. The posterior cortex was carefully preserved until controlled correction was achieved. Sequential distraction allowed gradual restoration of cervical lordosis while protecting the spinal cord and nerve roots.

Following satisfactory correction, trial spacers were inserted. A structural interbody cage packed with morselized local autograft and structural allograft was implanted into the prepared interspace.

An appropriately sized anterior cervical plate was applied spanning C5-C6. Vertebral body screws were inserted and secured according to the manufacturer's specifications. Final fluoroscopic images demonstrated satisfactory restoration of cervical alignment and appropriate implant position.

The wound was copiously irrigated, meticulous hemostasis was achieved, and the incision was closed in layers. Sterile dressings were applied.

The patient tolerated the procedure well without intraoperative complications. Sponge, needle, and instrument counts were correct at the completion of the procedure.

Findings

Rigid cervical kyphotic deformity centered at C5-C6 with severe anterior column contracture and bridging osteophytes. Excellent correction of cervical lordosis and sagittal alignment was achieved following anterior cervical osteotomy with stable anterior fixation.

Implants

* Structural interbody cage at C5-C6.

* Anterior cervical plate.

* Cervical fixation screws.

* Structural allograft.

* Morselized local autograft.

Check your answer

22220

22554 (or 22551, depending on the arthrodesis performed)

22845

22853

20930

20936

22220 already includes the anterior discectomy performed as part of the osteotomy. Do not report 63075 (anterior cervical discectomy) separately at the same level.

Arthrodesis, instrumentation, interbody cage, and bone graft codes may be reported separately when they are performed and appropriately documented.