Operative report Spinal procedure 2

Operative report 1

Preoperative Diagnosis:

1. Thoracolumbar degenerative scoliosis.

2. Thoracolumbar spinal instability from T10 through L1.

3. Chronic thoracolumbar back pain.

   
   

Postoperative Diagnosis:

1. Thoracolumbar degenerative scoliosis.

2. Thoracolumbar spinal instability from T10 through L1.

3. Chronic thoracolumbar back pain.

   
   

Procedure Performed:

1. Posterior/posterolateral arthrodesis, T10-L1.

2. Posterior segmental pedicle screw instrumentation from T10 through L1.

3. Placement of morselized local autograft and cancellous allograft for fusion.

   
   

Indication:

The patient is a 68-year-old individual with progressive thoracolumbar pain secondary to degenerative scoliosis and multilevel instability involving T10 through L1. Conservative management, including physical therapy, anti-inflammatory medications, spinal injections, and activity modification, failed to provide lasting relief. Radiographic studies demonstrated progressive deformity with segmental instability. Surgical stabilization with posterior thoracolumbar fusion was recommended. The risks, benefits, alternatives, and potential complications were discussed with the patient, and informed consent was obtained.

Description of the Procedure:

After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Neuromonitoring with somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) was established. The patient was positioned prone on a radiolucent Jackson spinal table with all pressure points adequately padded. Intravenous prophylactic antibiotics were administered prior to skin incision.

The thoracolumbar region was prepped and draped in the standard sterile fashion. Fluoroscopy was utilized to identify and confirm the operative levels. A midline posterior incision was made extending from T10 through L1. Dissection was carried through the subcutaneous tissue to the thoracolumbar fascia. The fascia was incised sharply in the midline, and meticulous subperiosteal dissection was performed bilaterally using Cobb elevators and electrocautery to expose the spinous processes, laminae, facet joints, pars interarticularis, and transverse processes of T10, T11, T12, and L1. Self-retaining retractors were placed to maintain exposure.

The facet joint capsules were excised, and the posterior bony elements were fully exposed. Fluoroscopy again confirmed the operative levels before instrumentation.

Pedicle screw entry sites were identified using standard anatomic landmarks. A high-speed burr was used to create the pedicle entry points. A pedicle awl and pedicle probe were advanced into each pedicle under fluoroscopic guidance. Each pedicle tract was palpated with a ball-tipped probe to confirm intact cortical walls without evidence of breach. The tracts were sequentially tapped, and appropriately sized pedicle screws were inserted bilaterally into T10, T11, T12, and L1. Screw position and trajectory were confirmed fluoroscopically.

Titanium rods were contoured to restore physiologic thoracolumbar sagittal alignment and seated into the pedicle screw heads bilaterally. Compression and distraction maneuvers were applied where appropriate to optimize alignment and stabilize the construct. Set screws were provisionally tightened, followed by final tightening using the manufacturer's calibrated torque-limiting device. Final fluoroscopic images demonstrated satisfactory spinal alignment and appropriate placement of all instrumentation.

Attention was then directed to the fusion. The transverse processes and facet joints from T10 through L1 were meticulously decorticated using a high-speed burr until healthy bleeding cancellous bone was encountered. Additional decortication of the posterolateral fusion bed was performed to maximize the surface area available for fusion.

Local autograft bone obtained during bony preparation was morselized and combined with cancellous allograft. The graft material was placed bilaterally over the decorticated transverse processes and facet joints within the posterolateral gutters from T10 through L1, establishing a continuous fusion mass.

The wound was copiously irrigated with sterile saline. Meticulous hemostasis was achieved using bipolar electrocautery, bone wax, and absorbable hemostatic agents. Final inspection confirmed stable instrumentation, satisfactory graft placement, and excellent hemostasis.

A closed-suction drain was 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, and the skin was closed with staples. Sterile dressings were applied.

The patient tolerated the procedure well without complications. All 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:

Multilevel thoracolumbar degenerative changes with facet arthropathy, degenerative scoliosis, and segmental instability involving T10 through L1. Stable posterior segmental fixation and satisfactory posterolateral fusion were achieved with restoration of spinal alignment.

Implants:

• Pedicle screws at T10, T11, T12, and L1.

• Bilateral titanium rods.

• Crosslink connector (if utilized).

• Morselized local autograft bone.

• Cancellous allograft bone.

Check your answer

CPT

22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic

22614 x2 Each additional vertebral segment

(T11 and T12)

22842 Posterior segmental instrumentation (3 to 6 vertebral segments)

20936 Autograft for spine surgery, local (obtained from same incision) (if documented)

20930 Allograft, morselized or placement of osteopromotive material, for spine surgery only (if documented)

Operative report 2

Preoperative Diagnosis:

1. Lumbar degenerative disc disease at L3-L4 and L4-L5.

2. Segmental lumbar instability.

3. Chronic mechanical low back pain.

Postoperative Diagnosis:

1. Lumbar degenerative disc disease at L3-L4 and L4-L5.

2. Segmental lumbar instability.

3. Chronic mechanical low back pain.

Procedure Performed:

1. Posterior lumbar interbody arthrodesis (PLIF), L3-L4 and L4-L5.

2. Placement of interbody biomechanical cages at L3-L4 and L4-L5.

3. Posterior segmental pedicle screw instrumentation from L3 through L5.

4. Placement of morselized local autograft and cancellous allograft for fusion.

Indication:

The patient is a 61-year-old individual with chronic mechanical low back pain secondary to multilevel degenerative disc disease and lumbar instability involving L3-L4 and L4-L5. Conservative treatment, including physical therapy, medications, and spinal injections, failed to provide adequate symptom relief. Imaging demonstrated advanced disc degeneration with instability but without significant central canal or foraminal stenosis requiring decompression. Surgical stabilization with posterior 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. Neuromonitoring was established, and the patient was positioned prone on a radiolucent spinal table. The lumbar spine was prepped and draped in the usual sterile fashion.

Fluoroscopy confirmed the operative levels. A midline posterior lumbar incision was made extending from L3 through L5. Subperiosteal dissection exposed the spinous processes, laminae, facet joints, and transverse processes bilaterally.

Pedicle screw entry sites were prepared using standard anatomical landmarks and fluoroscopic guidance. Appropriately sized pedicle screws were inserted bilaterally into L3, L4, and L5. Screw position was confirmed fluoroscopically.

Attention was first directed to the L3-L4 interspace. A limited laminotomy and partial facetectomy were performed only to gain access to the disc space. A posterior annulotomy was created, followed by discectomy performed solely to prepare the intervertebral space for arthrodesis and implant placement. The cartilaginous endplates were carefully prepared while preserving the subchondral bone. No decompression of the thecal sac or nerve roots was performed. Trial spacers were utilized, and an appropriately sized interbody biomechanical cage packed with morselized autograft and cancellous allograft was inserted into the disc space.

The identical procedure was then performed at L4-L5. A limited laminotomy and disc preparation were carried out exclusively for access and fusion. Following meticulous endplate preparation, a second interbody cage packed with bone graft was inserted under fluoroscopic guidance. Again, no decompression of the neural elements was performed.

Appropriately contoured titanium rods were secured to the pedicle screws bilaterally, and final tightening was completed according to the manufacturer's recommendations. Final fluoroscopic imaging confirmed satisfactory placement of the cages, instrumentation, and restoration of lumbar alignment.

The transverse processes and posterolateral fusion beds were decorticated using a high-speed burr. Remaining local autograft and cancellous allograft were placed over the decorticated posterolateral gutters to augment fusion.

The wound was irrigated thoroughly. Hemostasis was achieved. A closed-suction drain was placed. The fascia, subcutaneous tissue, and skin were closed in standard layered fashion. Sterile dressings were applied.

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

Findings:

Advanced degenerative disc disease with segmental instability at L3-L4 and L4-L5. Stable posterior interbody fusion and instrumentation were achieved. No significant neural compression requiring decompression was identified.

Implants:

• Interbody biomechanical cage, L3-L4.

• Interbody biomechanical cage, L4-L5.

• Pedicle screws at L3, L4, and L5.

• Bilateral titanium rods.

• Morselized local autograft bone.

• Cancellous allograft bone.

Check your answer

CPT -

22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare the interspace (other than for decompression); lumbar, single interspace (L3-L4)

22632 Each additional lumbar interspace (L4-L5)

22853 x2 Insertion of interbody biomechanical device(s) (one cage at L3-L4 and one cage at L4-L5)

22842 Posterior segmental instrumentation, 3 to 6 vertebral segments (L3-L5)

20936 Autograft for spine surgery, local, obtained through the same incision (if documented)

20930 Morselized allograft or osteopromotive material, for spine surgery only (if documented)

Note : This report intentionally documents that the laminotomy/discectomy was performed only to prepare the interspace for fusion, not for decompression, which is the distinguishing feature of 22630/22632

Operative report 3

Preoperative Diagnosis:

1. Lumbar degenerative disc disease at L4-L5.

2. Grade I degenerative spondylolisthesis at L4-L5.

3. Lumbar segmental instability.

4. Chronic mechanical low back pain.

Postoperative Diagnosis:

1. Lumbar degenerative disc disease at L4-L5.

2. Grade I degenerative spondylolisthesis at L4-L5.

3. Lumbar segmental instability.

4. Chronic mechanical low back pain.

Procedure Performed:

1. Combined posterior/posterolateral and posterior lumbar interbody arthrodesis (PLIF), L4-L5.

2. Placement of interbody biomechanical cage, L4-L5.

3. Posterior segmental pedicle screw instrumentation, L4-L5.

4. Placement of morselized local autograft and cancellous allograft.

Indication:

The patient is a 66-year-old individual with chronic low back pain secondary to advanced degenerative disc disease, grade I degenerative spondylolisthesis, and segmental instability at L4-L5. Conservative treatment including physical therapy, medications, epidural steroid injections, and activity modification failed to provide lasting relief. Imaging demonstrated marked disc degeneration and instability without additional pathology requiring decompression beyond that necessary for the fusion procedure. Surgical stabilization with combined posterior interbody and posterolateral arthrodesis was recommended. Risks, benefits, and alternatives were discussed, and informed consent was obtained.

Description of the 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. The patient was positioned prone on a radiolucent Jackson spinal table with all pressure points appropriately padded. Intravenous prophylactic antibiotics were administered prior to incision.

The lumbar spine was prepped and draped in the usual sterile fashion. Using fluoroscopic guidance, the L4-L5 level was identified and confirmed. A midline posterior lumbar incision was made, and dissection was carried through the subcutaneous tissue to the thoracolumbar fascia. The fascia was incised in the midline, and subperiosteal dissection exposed the spinous processes, laminae, facet joints, pars interarticularis, and transverse processes of L4 and L5 bilaterally.

Pedicle screw entry points were identified using standard anatomic landmarks. A high-speed burr was used to create the entry sites. The pedicles of L4 and L5 were cannulated with a pedicle probe, palpated with a ball-tipped feeler to confirm intact cortical walls, sequentially tapped, and appropriately sized pedicle screws were inserted bilaterally under fluoroscopic guidance.

Attention was then directed to the L4-L5 interspace. A limited laminotomy and medial facetectomy were performed only to obtain access to the disc space. A posterior annulotomy was created, and a complete discectomy was performed solely for preparation of the interspace for arthrodesis. The cartilaginous endplates were meticulously removed while preserving the underlying bony endplates. No additional decompression of the thecal sac or exiting nerve roots beyond that required to safely perform the interbody fusion was carried out.

Trial spacers were inserted to determine the appropriate implant size. The intervertebral space was packed with morselized local autograft mixed with cancellous allograft. An appropriately sized interbody biomechanical cage packed with the same graft material was inserted into the L4-L5 disc space under fluoroscopic guidance. Cage position and restoration of disc height were confirmed.

Titanium rods were contoured to restore physiologic lumbar lordosis and secured to the pedicle screws bilaterally. Compression across the construct was applied to optimize graft contact and spinal alignment. Set screws were tightened to the manufacturer's recommended torque specifications.

Attention was then directed to the posterolateral arthrodesis. The transverse processes of L4 and L5, as well as the lateral aspects of the facet joints, were thoroughly decorticated using a high-speed burr until healthy bleeding cancellous bone was encountered. Remaining morselized local autograft and cancellous allograft were placed generously within the bilateral posterolateral gutters over the decorticated transverse processes and facet joints, creating a robust posterolateral fusion bed to supplement the interbody fusion.

Final fluoroscopic imaging confirmed satisfactory placement of the pedicle screws, rods, and interbody cage with restoration of spinal alignment.

The wound was copiously irrigated with sterile saline. Hemostasis was achieved using bipolar electrocautery and absorbable hemostatic agents. A closed-suction drain was placed in the subfascial space. The fascia was closed with interrupted absorbable sutures, followed by layered closure of the subcutaneous tissue. The skin was closed with staples, and sterile dressings were applied.

The patient tolerated the procedure well without complications. Sponge, needle, and instrument counts were correct at the conclusion of the procedure. The patient was transferred to the recovery room in stable condition.

Findings:

Advanced degenerative disc disease with grade I degenerative spondylolisthesis and segmental instability at L4-L5. Stable posterior interbody fusion and posterolateral fusion were achieved with satisfactory restoration of disc height and spinal alignment.

Implants:

• Interbody biomechanical cage, L4-L5.

• Bilateral pedicle screws at L4 and L5.

• Bilateral titanium rods.

• Morselized local autograft bone.

• Cancellous allograft bone.

Check your answer

22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique, including laminectomy and/or discectomy sufficient to prepare the interspace (other than for decompression); single interspace, lumbar

22853 Insertion of interbody biomechanical device (intervertebral disc space

22840 Posterior non-segmental instrumentation (L4-L5)

20936 Autograft for spine surgery, local, obtained through the same incision (if documented)

20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (if documented)

Operative report 4

Preoperative Diagnosis

1. Recurrent left L3-L4 lumbar disc herniation.

2. Left L4 lumbar radiculopathy.

3. Status post previous left L3-L4 lumbar laminotomy and microdiscectomy.

Postoperative Diagnosis

Same.

Procedure Performed

Revision left L3-L4 hemilaminotomy with microscopic discectomy and decompression of the left L4 nerve root (posterior approach).

Indication

The patient is a 46-year-old individual with a prior history of left L3-L4 lumbar microdiscectomy who developed recurrent low back pain with severe left lower extremity radicular symptoms. MRI demonstrated a recurrent left paracentral L3-L4 disc herniation producing significant compression of the traversing left L4 nerve root at the previous operative level. Conservative treatment, including medications, physical therapy, and epidural steroid injections, failed to provide adequate relief. Revision posterior decompression and microscopic discectomy were therefore recommended.

Description of the 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 prior to incision. The patient was carefully positioned prone on a Wilson spinal frame with the abdomen free to minimize epidural venous congestion. All pressure points were appropriately padded.

The lumbar spine was prepped and draped in the standard sterile fashion. Fluoroscopy was utilized to localize the L3-L4 interspace, and the previous operative incision was identified.

The prior midline lumbar incision was reopened with a scalpel. Dissection was carried sharply through the subcutaneous tissue using electrocautery until the thoracolumbar fascia was identified. The fascia was incised longitudinally just left of the midline. The paraspinal musculature was elevated subperiosteally from the posterior elements of L3 and L4 using Cobb elevators and periosteal elevators. Self-retaining retractors were positioned to maintain exposure.

Fluoroscopy again confirmed the L3-L4 operative level.

The previous left laminotomy defect was identified without difficulty. Dense postoperative scar tissue and epidural fibrosis were encountered surrounding the prior operative site. The operating microscope was then brought into the operative field for microsurgical dissection and remained in use throughout the remainder of the procedure.

Using microsurgical technique, dense epidural scar tissue was meticulously dissected away from the underlying dura with microdissectors, Penfield elevators, and fine Kerrison rongeurs. Adhesions surrounding the traversing left L4 nerve root were carefully released. Extreme caution was exercised throughout the dissection because of the dense postoperative fibrosis. The dura remained intact without evidence of cerebrospinal fluid leakage.

The previous laminotomy defect was revised and slightly enlarged using a 3-mm Kerrison rongeur to improve visualization of the lateral recess and neural structures. Residual ligamentous tissue and small residual bony overgrowth were removed where necessary to optimize exposure.

The traversing left L4 nerve root was identified and carefully mobilized medially using a microsurgical nerve root retractor. A large recurrent left paracentral disc herniation was identified ventral to the nerve root, producing marked neural compression.

A cruciate annulotomy was performed with a microsurgical blade. Large recurrent extruded disc fragments were removed using pituitary rongeurs under microscopic visualization. Additional loose degenerative disc material was removed from within the intervertebral disc space. Straight and angled pituitary rongeurs were utilized to ensure complete removal of all accessible loose fragments.

The disc space and epidural compartment were carefully explored using right-angle nerve hooks and a ball-tipped nerve probe. No additional free fragments were identified. The traversing left L4 nerve root was inspected circumferentially and demonstrated complete decompression with restoration of normal mobility. The nerve root was freely mobile without residual ventral or lateral compression.

The operative field was copiously irrigated with warm sterile saline solution. Final microscopic inspection confirmed excellent decompression of the neural elements, complete hemostasis, and an intact dura without cerebrospinal fluid leak. Bipolar electrocautery and absorbable hemostatic material were utilized as necessary to achieve meticulous epidural hemostasis.

The microscope was removed from the field. The fascia was closed with interrupted #1 absorbable sutures. The subcutaneous tissue was reapproximated in multiple layers with absorbable sutures. Skin closure was performed using staples. Sterile dressings were applied.

The patient tolerated the procedure well without intraoperative complications. Sponge, needle, and instrument counts were correct ×2 at the completion of the procedure. The patient was awakened from anesthesia and transferred to the recovery room in stable condition with intact lower extremity motor function.

Findings

Previous left L3-L4 laminotomy defect with extensive epidural fibrosis and dense postoperative scar tissue. Large recurrent left paracentral L3-L4 disc herniation producing significant compression of the traversing left L4 nerve root. Complete microscopic decompression of the nerve root was achieved following revision hemilaminotomy and microdiscectomy.

Implants : None.

Check your answer

63042 : Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar

Operative report 5

Preoperative Diagnosis

1. Lumbar spondylolisthesis at L4-L5 and L5-S1.

2. Lumbar spinal instability.

3. Neurogenic claudication.

4. Bilateral lumbar radiculopathy.

5. Lumbar degenerative disc disease with foraminal stenosis.

Postoperative Diagnosis

Same.

Procedure Performed

1. Anterior lumbar interbody arthrodesis (ALIF) at **L4-L5**.

2. Anterior lumbar interbody arthrodesis (ALIF) at **L5-S1**.

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

4. Placement of **separate anterior lumbar plate fixation** spanning L4-L5 and L5-S1.

5. Posterior/posterolateral arthrodesis from L4 through S1.

6. Posterior non-segmental pedicle screw instrumentation from L4 to S1.

7. Computer-assisted stereotactic navigation for placement of posterior pedicle screws.

8. Placement of structural allograft and local autograft for fusion.

Indication

The patient presented with progressive mechanical low back pain, bilateral lumbar radiculopathy, neurogenic claudication, and instability secondary to grade I degenerative spondylolisthesis at L4-L5 and L5-S1. MRI demonstrated advanced degenerative disc disease with foraminal stenosis and instability at both levels. The patient had failed extensive conservative management including physical therapy, medications, and epidural steroid injections. Circumferential lumbar fusion was recommended to restore stability, relieve neural compression indirectly, and promote solid arthrodesis.

Description of the Procedure

After informed consent was obtained, the patient was brought to the operating room and placed under general endotracheal anesthesia. Intravenous antibiotics were administered prior to incision.

Anterior Stage

The patient was positioned supine on a radiolucent operating table. The abdomen was prepped and draped in the usual sterile fashion.

A lower midline abdominal incision was made. The anterior retroperitoneal approach to the lumbar spine was performed by the exposure surgeon. The retroperitoneal space was developed, and the great vessels were mobilized to expose the L4-L5 and L5-S1 disc spaces. Fluoroscopy confirmed both operative levels.

L4-L5

A complete annulotomy was performed followed by thorough discectomy using pituitary rongeurs, curettes, and disc shavers. Cartilaginous endplates were meticulously prepared while preserving the subchondral bone. Sequential distractors and trial implants restored disc height and segmental lordosis.

A structural allograft-filled titanium interbody cage was inserted into the L4-L5 disc space under fluoroscopic guidance with excellent restoration of disc height and alignment.

A **separate low-profile anterior lumbar plate** was then positioned over the anterior aspect of the L4-L5 vertebral bodies. Vertebral body screws were inserted into L4 and L5 under fluoroscopic guidance. The screws were locked according to the manufacturer's specifications. Fluoroscopy confirmed satisfactory plate and screw placement.

L5-S1

Attention was directed to the L5-S1 interspace. A complete discectomy was performed in similar fashion. Endplate preparation was completed using curettes and rasps until healthy bleeding bone was encountered.

A second structural allograft-packed titanium interbody cage was inserted into the L5-S1 disc space under fluoroscopic guidance.

A **second separate anterior lumbar plate** was applied across L5-S1. Vertebral body screws were inserted into L5 and S1 and secured according to the manufacturer's specifications. Final fluoroscopy demonstrated excellent implant position and restoration of lumbar lordosis.

The anterior wound was copiously irrigated. Hemostasis was confirmed. The retroperitoneal contents were allowed to return to their normal position. The fascial layers, subcutaneous tissues, and skin were closed in standard layered fashion.

Posterior Stage

The patient was carefully repositioned prone on a Jackson spinal table. All pressure points were padded. The lumbar spine was again prepped and draped in sterile fashion.

A midline posterior lumbar incision extending from L4 through S1 was made. Subperiosteal dissection exposed the spinous processes, laminae, facet joints, transverse processes, and sacral ala.

Computer-assisted stereotactic navigation was registered and verified. Navigation-guided pedicle screw trajectories were planned for L4 and S1. Under navigational guidance, pedicle screws were inserted with excellent accuracy. Fluoroscopy confirmed satisfactory hardware placement.

Appropriately contoured rods were secured to the pedicle screws, creating a **posterior non-segmental instrumentation construct spanning L4 to S1**. Compression across the construct restored lumbar lordosis and improved reduction of the spondylolisthesis. Final locking caps were tightened using the manufacturer's torque-limiting device.

The transverse processes of L4, L5, and the sacral ala were thoroughly decorticated using a high-speed burr. Local autograft harvested during exposure was combined with structural allograft and placed within the bilateral posterolateral gutters to complete posterolateral arthrodesis from L4 through S1.

Final anteroposterior and lateral fluoroscopic images demonstrated satisfactory restoration of lumbar alignment, appropriate placement of the interbody cages, anterior plates, posterior instrumentation, and excellent overall construct stability.

Both wounds were copiously irrigated. Hemostasis was meticulously achieved. Closed-suction drains were placed as needed. Layered closure of the fascia, subcutaneous tissue, and skin was completed in standard fashion, and 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. The patient was extubated and transferred to the recovery unit in stable condition.

Findings

Grade I degenerative spondylolisthesis at L4-L5 and L5-S1 with advanced disc degeneration, foraminal stenosis, and segmental instability. Restoration of disc height and lumbar lordosis was achieved following two-level anterior lumbar interbody fusion with separate anterior plate fixation. Stable posterior non-segmental instrumentation and posterolateral fusion were successfully completed.

Implants

* Titanium interbody cage at L4-L5.

* Titanium interbody cage at L5-S1.

* Separate anterior lumbar plate at L4-L5.

* Separate anterior lumbar plate at L5-S1.

* Anterior vertebral body screws.

* Posterior pedicle screw and rod construct from L4 to S1.

* Structural allograft.

* Local autograft.

Check your answer

• 22558 – Anterior lumbar interbody arthrodesis, first interspace (L4-L5)

• +22585 – Additional anterior lumbar interspace (L5-S1)

• 22853 ×2 – Insertion of biomechanical interbody devices (L4-L5 and L5-S1)

• 22845 – Anterior instrumentation (separate anterior lumbar plate fixation)

• 22612 – Posterolateral lumbar arthrodesis, first level

• +22614 – Each additional lumbar fusion level

• 22840 – Posterior non-segmental instrumentation

• 61783 – Computer-assisted stereotactic navigation for spinal instrumentation

• 20931 – Structural allograft for spinal fusion

Operative report 6

Preoperative Diagnosis

Thoracic spondylotic myelopathy

T7–T8 degenerative disc disease with thoracic spinal stenosis

Postoperative Diagnosis

Same.

Procedure Performed

* Anterior thoracic discectomy and decompression at T7–T8

* Anterior thoracic interbody arthrodesis at T7–T8

* Placement of interbody biomechanical device at T7–T8

* Harvest of corticocancellous autograft from the left iliac crest through a separate incision

* Placement of morselized allograft

* Fluoroscopic guidance

Indications

The patient presented with progressive mid-thoracic pain, lower extremity weakness, gait instability, and signs of thoracic myelopathy. MRI demonstrated severe degenerative disc disease with central canal stenosis at T7–T8 resulting in spinal cord compression. Conservative treatment had failed, and surgical intervention was recommended.

Operative Technique

After induction of general anesthesia, the patient was positioned in the lateral decubitus position. The thoracic region and the left iliac crest were prepped and draped in the usual sterile fashion. Fluoroscopy was utilized throughout the procedure to confirm the operative level.

Attention was first directed to the left iliac crest. Through a separate skin incision, dissection was carried down to the iliac crest. Adequate corticocancellous autograft was harvested using osteotomes and curettes. Hemostasis was obtained, the donor site was irrigated, and the wound was closed in layers.

A standard left anterolateral thoracic approach was then performed to expose the T7–T8 intervertebral disc space. The appropriate level was confirmed fluoroscopically.

The T7–T8 disc was excised in its entirety. Cartilaginous endplates were meticulously prepared while preserving the integrity of the subchondral bone. Posterior osteophytes and compressive disc material were removed, providing satisfactory decompression of the spinal canal and adjacent neural elements.

Trial spacers were used to determine the appropriate implant size. An interbody biomechanical device was packed with the harvested iliac crest autograft combined with morselized allograft and inserted into the prepared T7–T8 disc space under fluoroscopic guidance. After satisfactory positioning of the implant, fixation was achieved by advancing **integrated fixation screws through the implant into the adjacent T7 and T8 vertebral bodies** according to the implant manufacturer's recommended technique. Final fluoroscopic imaging confirmed appropriate implant position, satisfactory purchase of the fixation screws, restoration of disc height, and maintenance of spinal alignment.

The remaining autograft and morselized allograft were placed around the interbody device within the prepared fusion bed to promote arthrodesis.

The operative field was irrigated thoroughly. Hemostasis was achieved. A thoracic drain was placed, and the incision was closed in layers. Sterile dressings were applied.

The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

Check your answer

• 22556 – Anterior thoracic interbody arthrodesis, single interspace

• +22853 – Insertion of interbody biomechanical device

• 20937 – Autograft for spine surgery obtained through a separate skin/fascial incision

• 20930 – Morselized allograft

Integrated fixation screws used to secure the interbody biomechanical device. By itself, this documentation does not establish a separately reportable anterior instrumentation code. Separate instrumentation codes require documentation that supports placement of distinct spinal instrumentation in accordance with CPT guidelines.