Operative report Spinal procedure 1

Operative report 1

Preoperative Diagnosis :Cervical spondylotic stenosis with cervical radiculopathy and degenerative disc disease at C5-C6.

Postoperative Diagnosis:Cervical spondylotic stenosis with cervical radiculopathy and degenerative disc disease at C5-C6.

Procedure Performed:

1. Anterior cervical discectomy and fusion (ACDF), C5-C6.

2. Placement of interbody cage, C5-C6.

3. Anterior cervical plate fixation, C5-C6.

4. Placement of local autograft bone.

Indication:

The patient is a 56-year-old individual with persistent neck pain radiating into the right upper extremity, associated with numbness and weakness, secondary to cervical spondylosis and degenerative disc disease at C5-C6. Conservative management, including medications, physical therapy, and activity modification, failed to provide adequate relief. MRI demonstrated significant disc degeneration with posterior osteophyte formation causing central canal stenosis and foraminal narrowing with compression of the spinal cord and exiting nerve roots. Surgical intervention was recommended to decompress the neural elements and stabilize the cervical spine. The risks, benefits, and alternatives were discussed, and informed consent was obtained.

Description of the Procedure:

The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without complication. Neuromonitoring was utilized throughout the procedure. The neck was positioned in slight extension, and all pressure points were adequately padded. Fluoroscopy was used to confirm the operative level.

The anterior cervical region was prepped and draped in the usual sterile fashion. A transverse skin incision was made along a natural skin crease over the right anterior neck. Dissection was carried through the subcutaneous tissue and platysma. The standard Smith-Robinson anterior cervical approach was utilized by developing the plane between the sternocleidomastoid muscle and carotid sheath laterally and the trachea and esophagus medially. The prevertebral fascia was incised, and the longus colli muscles were elevated bilaterally. Self-retaining retractors were placed.

Intraoperative fluoroscopy confirmed the C5-C6 level. Caspar distraction pins were inserted into the adjacent vertebral bodies, and gentle distraction was applied. A complete anterior cervical discectomy was performed using pituitary rongeurs, curettes, and disc shavers. The cartilaginous endplates were meticulously removed while preserving the integrity of the bony endplates to prepare the intervertebral space for fusion.

Posterior osteophytes along the vertebral endplates were removed using a high-speed burr and Kerrison rongeurs. The posterior longitudinal ligament was opened and excised where necessary. Thorough decompression of the spinal canal and bilateral neural foramina was performed until the spinal cord and exiting nerve roots were freely decompressed without residual compression. Adequate decompression was confirmed visually and with a nerve hook.

Trial spacers were inserted to determine the appropriate implant size. The intervertebral space was irrigated, and an appropriately sized structural interbody cage packed with bone graft material was inserted into the prepared disc space under fluoroscopic guidance, restoring disc height and cervical alignment. The implant position was confirmed in both anteroposterior and lateral fluoroscopic views.

An appropriately sized anterior cervical plate was then positioned across C5-C6 and secured with locking screws into the C5 and C6 vertebral bodies according to the manufacturer's recommendations. Final fluoroscopic imaging confirmed satisfactory implant position, restoration of alignment, and stable fixation.

The wound was thoroughly irrigated with sterile saline. Meticulous hemostasis was achieved using bipolar electrocautery and hemostatic agents. The retractors were removed carefully, ensuring no injury to the surrounding soft tissues. The platysma was reapproximated with absorbable sutures, the subcutaneous tissue was closed in layers, and the skin was closed with a running subcuticular absorbable suture followed by sterile skin adhesive. A sterile dressing was applied.

The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition with all sponge, needle, and instrument counts correct.

Findings:

Severe degenerative disc disease at C5-C6 with disc space collapse, posterior disc-osteophyte complex, hypertrophic uncovertebral osteophytes, central canal stenosis, bilateral foraminal stenosis, and compression of the spinal cord and exiting C6 nerve roots. Adequate decompression and stable anterior interbody fusion were achieved.

Implants:

* Structural interbody fusion cage at C5-C6.

* Anterior cervical plate spanning C5-C6.

* Locking anterior cervical screws.

* Bone graft material placed within the interbody cage.

Check your answer

CPT

22551 Anterior cervical discectomy and fusion, single interspace

22853 Insertion of interbody biomechanical device

22845 Anterior instrumentation, 2–3 vertebral segments

20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision

Operative report 2

Preoperative Diagnosis: Cervical degenerative disc disease with cervical instability at C3-C4 and C4-C5.

Postoperative Diagnosis: Cervical degenerative disc disease with cervical instability at C3-C4 and C4-C5.

Procedure Performed:

1. Anterior cervical interbody arthrodesis, C3-C4 and C4-C5.

2. Placement of interbody fusion cages at C3-C4 and C4-C5.

3. Anterior cervical plate fixation from C3 through C5.

4. Placement of allograft bone for spinal fusion.

Indication:

The patient is a 58-year-old individual with chronic axial neck pain secondary to multilevel cervical degenerative disc disease and segmental instability at C3-C4 and C4-C5. Conservative management, including medications, physical therapy, and activity modification, failed to provide lasting relief. Imaging demonstrated advanced disc degeneration with instability but no significant central canal or foraminal stenosis requiring decompression. After discussing the risks, benefits, and alternatives, the patient elected to proceed with anterior cervical interbody fusion.

Description of the Procedure

After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without complication. The neck was positioned in slight extension, and fluoroscopy was used to identify the operative levels.

The anterior cervical region was prepped and draped in the usual sterile fashion. A transverse incision was made along a natural skin crease on the right anterior neck. Dissection was carried through the platysma, and the standard Smith-Robinson anterior cervical approach was utilized. The carotid sheath was retracted laterally while the trachea and esophagus were retracted medially. The prevertebral fascia was opened, and the longus colli muscles were elevated to expose the anterior cervical spine.

Fluoroscopy confirmed the C3-C4 and C4-C5 disc spaces. Caspar distraction pins were placed to provide gentle distraction. A **minimal discectomy** was performed at each level solely to prepare the intervertebral spaces for arthrodesis. The cartilaginous endplates were carefully removed while preserving the subchondral bone. **No decompression of the spinal cord, posterior longitudinal ligament, neural foramina, or nerve roots was performed**, as there was no indication for decompression.

Trial spacers were used to determine the appropriate implant sizes. Structural interbody fusion cages packed with morselized allograft bone were inserted into the C3-C4 and C4-C5 disc spaces under fluoroscopic guidance, restoring disc height and maintaining cervical alignment.

An appropriately sized anterior cervical plate was positioned spanning C3 through C5 and secured with locking screws into the C3, C4, and C5 vertebral bodies. Final fluoroscopic imaging confirmed satisfactory placement of the interbody devices and anterior instrumentation.

The wound was irrigated thoroughly, and meticulous hemostasis was achieved. The platysma was reapproximated with absorbable sutures. The subcutaneous tissue was closed in layers, and the skin was closed with a running subcuticular absorbable suture and skin adhesive. A sterile dressing was applied.

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

Findings:

Degenerative disc disease and segmental instability at C3-C4 and C4-C5 without significant central canal or foraminal stenosis. Stable anterior interbody fusion and instrumentation were achieved.

Implants:

* Interbody fusion cage, C3-C4.

* Interbody fusion cage, C4-C5.

* Anterior cervical plate spanning C3-C5.

* Locking cervical screws.

* Morselized allograft bone.

Check your answer

CPT -

22554 Anterior cervical interbody arthrodesis, first level (C3-C4)

22585 Each additional interspace (C4-C5)

22853 x2 Insertion of interbody biomechanical device at C3-C4 and C4-C5

22845 Anterior cervical plate fixation (C3-C5)

20930 Morselized allograft

Note : (Do not report 22554 in conjunction with 63075, even if performed by a separate individual. To report anterior cervical discectomy and interbody fusion at the same level during the same session, use 22551)

Operative report 3

Preoperative Diagnosis:Cervical spondylosis with spinal stenosis and cervical radiculopathy at C3-C4 and C4-C5.

Postoperative Diagnosis:Cervical spondylosis with spinal stenosis and cervical radiculopathy at C3-C4 and C4-C5.

Procedure Performed:

1. Anterior cervical discectomy and fusion (ACDF), C3-C4.

2. Anterior cervical discectomy with decompression of the spinal cord and bilateral nerve roots, C4-C5.

3. Placement of interbody biomechanical cage, C3-C4.

4. Anterior cervical plate fixation, C3-C4.

5. Placement of morselized allograft bone.

Indication:

The patient is a 59-year-old individual with progressive neck pain radiating into both upper extremities associated with numbness and weakness. MRI demonstrated severe degenerative disc disease with spinal canal stenosis at C3-C4 resulting in instability requiring fusion. An additional disc herniation with foraminal stenosis was present at C4-C5 causing compression of the spinal cord and exiting nerve roots without evidence of instability. After failure of conservative treatment, surgical intervention was recommended.

Description of the Procedure:

After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without complication. The neck was positioned in slight extension, and the anterior cervical region was prepped and draped in the usual sterile fashion.

A transverse incision was made over the anterior cervical spine, and a standard Smith-Robinson approach was utilized. The prevertebral fascia was opened, and fluoroscopy confirmed the operative levels.

Attention was first directed to the C3-C4 level. Caspar distraction pins were inserted, and a complete anterior cervical discectomy was performed. The cartilaginous endplates were prepared for arthrodesis. Posterior osteophytes were removed, and the posterior longitudinal ligament was opened to achieve complete decompression of the spinal cord and bilateral exiting nerve roots. Following adequate decompression, a biomechanical interbody cage packed with morselized allograft bone was inserted into the disc space. An anterior cervical plate was applied across C3 and C4 and secured with locking screws. Implant position was confirmed fluoroscopically.

Attention was then directed to the C4-C5 level. A complete anterior cervical discectomy was performed. Posterior osteophytes were removed using a high-speed burr and Kerrison rongeurs. The posterior longitudinal ligament was opened, and thorough decompression of the spinal cord and bilateral exiting nerve roots was accomplished. Following satisfactory decompression, the disc space was irrigated. No interbody device, bone graft, instrumentation, or arthrodesis was performed at the C4-C5 level.

Final fluoroscopic images confirmed satisfactory placement of the implants at C3-C4. Hemostasis was achieved. The wound was irrigated, and the platysma, subcutaneous tissue, and skin were closed in layers. A sterile dressing was applied.

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

Findings:

Severe cervical spondylosis with disc degeneration and central canal stenosis at C3-C4 producing spinal cord compression and instability requiring fusion. Additional disc herniation and foraminal stenosis at C4-C5 causing compression of the spinal cord and bilateral nerve roots, successfully decompressed without fusion.

Implants:

• Interbody biomechanical cage, C3-C4.

• Anterior cervical plate spanning C3-C4.

• Locking cervical screws.

• Morselized allograft bone.

Check your answer

CPT -

22551 Arthrodesis, anterior interbody technique, including discectomy, osteophytectomy, and decompression; cervical below C2, single interspace (C3-C4)

63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace (C4-C5)

22853 Insertion of interbody biomechanical device (C3-C4)

22845 Anterior instrumentation, 2-3 vertebral segments (C3-C4)

20930 Morselized allograft (if used)

Since the procedures are performed at different cervical levels, there is no bundling between 22551 and 63075 in this scenario.

Operative report 4

Preoperative Diagnosis:

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

2. Lumbar spinal stenosis with neurogenic claudication.

3. Lumbar radiculopathy.

Postoperative Diagnosis:

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

2. Lumbar spinal stenosis with neurogenic claudication.

3. Lumbar radiculopathy.

Procedure Performed:

1. Anterior lumbar interbody fusion (ALIF), L3-L4 and L4-L5.

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

3. Placement of morselized allograft bone.

4. Posterior decompressive laminectomy with bilateral medial facetectomies and foraminotomies at L3-L4 and L4-L5.

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

Indication:The patient is a 63-year-old individual with longstanding low back pain associated with bilateral lower extremity pain, numbness, and neurogenic claudication. Conservative treatment, including physical therapy, anti-inflammatory medications, epidural steroid injections, and activity modification, failed to provide lasting relief. MRI demonstrated advanced degenerative disc disease with loss of disc height and instability at L3-L4 and L4-L5, along with severe central canal and bilateral foraminal stenosis. Surgical intervention consisting of anterior lumbar interbody fusion followed by posterior decompression and stabilization was recommended. The risks, benefits, and alternatives 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 supine under general endotracheal anesthesia. Intravenous antibiotics were administered. The abdomen and lumbar spine were prepped and draped in the usual sterile fashion.

A vascular surgeon performed a standard retroperitoneal exposure of the lumbar spine, exposing the L3-L4 and L4-L5 disc spaces. Fluoroscopy confirmed the operative levels.

Attention was first directed to the L3-L4 disc space. A complete annulotomy was performed, followed by minimal discectomy limited to preparation of the intervertebral space for arthrodesis. The cartilaginous endplates were carefully prepared while preserving the bony endplates. No anterior decompression of the spinal canal or nerve roots was performed. Trial spacers were used to determine the appropriate implant size. A biomechanical interbody fusion cage packed with morselized allograft bone was inserted under fluoroscopic guidance.

The identical procedure was then performed at the L4-L5 level. Following confirmation of satisfactory implant position and restoration of disc height, the anterior wound was irrigated and closed in layers by the exposure surgeon.

The patient was then carefully repositioned prone on a radiolucent spinal table. The lumbar spine was reprepped and draped in sterile fashion.

A midline posterior lumbar incision was made extending from L3 through L5. Subperiosteal dissection exposed the posterior elements bilaterally. Fluoroscopy again confirmed the operative levels.

A decompressive laminectomy was performed at L3-L4 and L4-L5. Hypertrophied ligamentum flavum was excised. Bilateral medial facetectomies and foraminotomies were completed to fully decompress the traversing and exiting nerve roots. Adequate decompression of the thecal sac and neural foramina was confirmed.

Pedicle screws were placed bilaterally into L3, L4, and L5 under fluoroscopic guidance. Appropriately contoured rods were secured to the pedicle screws, and final tightening was performed according to the manufacturer's recommendations. Final fluoroscopic imaging confirmed satisfactory placement of all instrumentation and restoration of lumbar alignment.

The wound was copiously irrigated. Hemostasis was achieved. A closed-suction drain was placed. 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 and was transferred to the recovery room in stable condition.

Findings:

Advanced degenerative disc disease with segmental instability at L3-L4 and L4-L5. Severe central canal stenosis and bilateral foraminal stenosis were present at both levels. Excellent restoration of disc height was achieved with anterior interbody fusion, followed by satisfactory posterior neural decompression and stable pedicle screw fixation.

Implants:

• Biomechanical interbody fusion cage, L3-L4.

• Biomechanical interbody fusion cage, L4-L5.

• Bilateral pedicle screws at L3, L4, and L5.

• Titanium rods.

• Morselized allograft bone.

Check your answer

22558 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar (L3-L4)

22585 Each additional interspace (L4-L5)

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

63047 Laminectomy, facetectomy and foraminotomy, lumbar; single vertebral segment (L3-L4)

63048 Each additional lumbar segment (L4-L5)

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

20930 Allograft, morselized (if used)

Note : There is no combination code for Anterior interbody fusion with Decompression for Lumbar and Thoracic

Operative report 5

Preoperative Diagnosis:

1. Severe cervical spinal stenosis at C3-C4.

2. Cervical spondylotic myelopathy.

3. Cervical degenerative disc disease with spinal cord compression.

Postoperative Diagnosis:

1. Severe cervical spinal stenosis at C3-C4.

2. Cervical spondylotic myelopathy.

3. Cervical degenerative disc disease with spinal cord compression.

Procedure Performed:

1. Anterior cervical discectomy and fusion (ACDF), C3-C4.

2. Placement of interbody biomechanical cage, C3-C4.

3. Anterior cervical plate fixation, C3-C4.

4. Posterior cervical laminectomy, C3-C4.

5. Placement of morselized allograft bone.

Indication:

The patient is a 67-year-old individual with progressive cervical myelopathy manifested by gait imbalance, bilateral upper extremity weakness, hand clumsiness, and neck pain. MRI demonstrated severe ventral disc-osteophyte compression at C3-C4 along with significant posterior element hypertrophy producing circumferential spinal cord compression. Due to both anterior and posterior compressive pathology, a combined anterior and posterior decompression with stabilization was recommended. The risks, benefits, and alternatives were discussed, and informed consent was obtained.

Description of the Procedure:After induction of general endotracheal anesthesia, the patient was positioned supine. The anterior cervical region was prepped and draped in the usual sterile fashion.

A standard Smith-Robinson anterior cervical approach was performed. Fluoroscopy confirmed the C3-C4 level. A complete anterior cervical discectomy was carried out. The cartilaginous endplates were prepared for fusion. Posterior osteophytes were removed using a high-speed burr and Kerrison rongeurs. The posterior longitudinal ligament was opened, and complete decompression of the spinal cord and bilateral exiting nerve roots was achieved. An appropriately sized interbody biomechanical cage packed with morselized allograft bone was inserted into the C3-C4 disc space. An anterior cervical plate was secured to C3 and C4 with locking screws. Fluoroscopy confirmed satisfactory implant placement.

The anterior wound was irrigated and closed in layers. Sterile dressings were applied.

The patient was then carefully repositioned prone on a radiolucent spinal table. The posterior cervical spine was prepped and draped in the usual sterile fashion.

A midline posterior cervical incision was made over C3-C4. Subperiosteal dissection exposed the posterior elements. Fluoroscopy confirmed the operative level.

A complete laminectomy of C3 and the superior portion of C4 was performed using a high-speed burr and Kerrison rongeurs. The hypertrophied ligamentum flavum was excised, resulting in wide decompression of the dorsal aspect of the spinal cord. The spinal cord was noted to be freely decompressed throughout the operative level.

The wound was copiously irrigated. Meticulous hemostasis was achieved. The fascia, subcutaneous tissue, and skin were closed in layers, and sterile dressings were applied.

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

Findings:

Severe circumferential cervical spinal stenosis at C3-C4 with ventral disc-osteophyte complex and marked posterior element hypertrophy producing significant spinal cord compression. Adequate anterior and posterior decompression was achieved with stable anterior interbody fusion.

Implants:

• Interbody biomechanical fusion cage, C3-C4.

• Anterior cervical plate.

• Locking cervical screws.

• Morselized allograft bone.

Check your answer

22551 Anterior cervical discectomy and fusion (ACDF), C3-C4

22853 Insertion of interbody biomechanical device

22845 Anterior cervical instrumentation

20930 Morselized allograft

63045 Posterior cervical laminectomy with decompression, C3-C4

63048 Posterior cervical laminectomy with decompression, C4-C5

Note: Although 22551 includes the anterior decompression at C3-C4, the posterior laminectomy (63045) is separately reportable because it is performed through a distinct posterior surgical approach to decompress the dorsal aspect of the spinal cord. This is a recognized 360° cervical decompression and fusion procedure in appropriate clinical circumstances.

Operative report 6

Preoperative Diagnosis:

1. Multilevel cervical and cervicothoracic degenerative disc disease at C6-C7, C7-T1, and T1-T2.

2. Segmental spinal instability.

3. Chronic axial neck pain.

Postoperative Diagnosis:

1. Multilevel cervical and cervicothoracic degenerative disc disease at C6-C7, C7-T1, and T1-T2.

2. Segmental spinal instability.

3. Chronic axial neck pain.

Procedure Performed:

1. Anterior interbody arthrodesis, C6-C7, C7-T1, and T1-T2.

2. Placement of structural allograft at C6-C7, C7-T1, and T1-T2.

Indication:

The patient is a 62-year-old individual with longstanding neck pain secondary to advanced multilevel degenerative disc disease and segmental instability involving C6-C7, C7-T1, and T1-T2. The patient failed extensive conservative treatment including physical therapy, medications, and activity modification. Imaging demonstrated advanced disc degeneration with collapse of the involved disc spaces and mechanical instability without significant spinal cord or nerve root compression requiring decompression. Surgical stabilization with multilevel anterior interbody arthrodesis was recommended. Risks, benefits, and alternatives were discussed, and informed consent was obtained.

Description of the Procedure:

The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without complication. The neck and upper thorax were positioned in slight extension. The anterior cervical and upper thoracic regions were prepped and draped in the usual sterile fashion.

A standard left-sided anterior cervical approach was utilized with extension inferiorly to adequately expose the C6-C7, C7-T1, and T1-T2 disc spaces. Fluoroscopy confirmed the operative levels.

Attention was first directed to the C6-C7 interspace. A limited annulotomy was performed followed by minimal discectomy solely to prepare the intervertebral space for arthrodesis. The cartilaginous endplates were carefully prepared while preserving the underlying bony endplates. No decompression of the spinal cord, posterior longitudinal ligament, neural foramina, or nerve roots was performed. An appropriately sized structural allograft was impacted into the prepared disc space, achieving excellent fit and restoration of disc height.

The identical procedure was then performed at C7-T1. Minimal discectomy was carried out only for preparation of the fusion bed. Following meticulous endplate preparation, a structural allograft was inserted into the interspace. No decompression was performed.

Attention was then directed to T1-T2. Minimal discectomy was again performed solely for preparation of the arthrodesis site. Following preparation of the endplates, an appropriately sized structural allograft was inserted into the disc space. No decompression or instrumentation was required.

Final fluoroscopic imaging confirmed satisfactory positioning of the structural allografts and restoration of alignment across all fused levels. The wound was irrigated thoroughly, and meticulous hemostasis was achieved. The platysma was reapproximated with absorbable sutures. The subcutaneous tissue was closed in layers, and the skin was closed with a running subcuticular suture. A sterile dressing was applied.

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

Findings:

Advanced multilevel degenerative disc disease with significant disc space collapse and mechanical instability at C6-C7, C7-T1, and T1-T2. Stable anterior interbody arthrodesis was achieved at all three levels. No significant ventral neural compression requiring decompression was identified.

Implants:

• Structural allograft, C6-C7.

• Structural allograft, C7-T1.

• Structural allograft, T1-T2.

Check your answer

22554 Anterior interbody arthrodesis, first interspace (C6-C7)

22585 x2 Each additional interspace (C7-T1 and T1-T2)

20931 Structural allograft for spine surgery (one per fused interspace)

Note : 22556 primary code is not coded for thoracic as only highest level should be coded.

Operative report 7

Preoperative Diagnosis:

1. Degenerative disc disease at L5-S1.

2. Mechanical low back pain.

3. Lumbar spinal instability at L5-S1.

Postoperative Diagnosis:

1. Degenerative disc disease at L5-S1.

2. Mechanical low back pain.

3. Lumbar spinal instability at L5-S1.

Procedure Performed:

1. Presacral interbody arthrodesis (AxiaLIF), L5-S1.

2. Posterior percutaneous pedicle screw instrumentation at L5-S1 with fluoroscopic image guidance.

Indication:

The patient is a 54-year-old individual with chronic mechanical low back pain secondary to advanced degenerative disc disease and instability at L5-S1. Conservative treatment, including physical therapy, anti-inflammatory medications, epidural steroid injections, and activity modification, failed to provide adequate relief. MRI demonstrated severe degeneration and collapse of the L5-S1 disc space without significant central canal stenosis requiring formal decompression. Surgical stabilization was recommended. After discussing the risks, benefits, and alternatives, informed consent was obtained.

Description of the Procedure:

The patient was brought to the operating room and placed prone on a radiolucent spinal table after induction of general endotracheal anesthesia. Intravenous antibiotics were administered. The lumbosacral and presacral regions were prepped and draped in the usual sterile fashion.

Using fluoroscopic image guidance, a small paracoccygeal incision was made adjacent to the coccyx. Blunt dissection was carried through the presacral soft tissues to establish the presacral working corridor. A guidewire was advanced under continuous biplanar fluoroscopic guidance into the L5-S1 disc space.

Sequential dilators were introduced over the guidewire. The L5-S1 disc space was entered, and a complete discectomy was performed. Cartilaginous endplates were removed, and the intervertebral space was thoroughly prepared for arthrodesis while preserving the bony endplates.

Bone graft material was packed into the prepared disc space. A presacral interbody fusion implant was advanced across the L5-S1 interspace under fluoroscopic guidance, achieving restoration of disc height and stable interbody fixation. Implant position was confirmed in anteroposterior and lateral fluoroscopic views.

Attention was then directed to the posterior lumbar spine. Through bilateral percutaneous stab incisions, pedicle screws were inserted into L5 and S1 under fluoroscopic image guidance. Appropriately contoured rods were inserted and secured to the pedicle screws. Final tightening was performed according to the manufacturer's recommendations. Final fluoroscopic imaging confirmed satisfactory placement of the interbody implant and posterior instrumentation with restoration of lumbar alignment.

All wounds were irrigated thoroughly. Hemostasis was achieved. The fascial layers, subcutaneous tissue, and skin were closed in the 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 significant disc space collapse and segmental instability at L5-S1. Successful presacral interbody fusion and posterior pedicle screw stabilization were achieved with satisfactory implant position confirmed fluoroscopically.

Implants:

* Presacral interbody fusion implant, L5-S1.

* Bilateral pedicle screws at L5 and S1.

* Titanium rods.

* Bone graft material.

Check your answer

22586 : Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace