Alfaro33
Networker
Coding 22610 and 22614. Having trouble with the reporting of the cement augmentation. I do not believe 22510 percutaneous vertebroplasty would be supported here since this is an open procedure. Any feedback would be appreciated!
Postoperative Diagnosis
T8 fracture dislocation, Chance fracture
Operation
T5-T11 instrumented fusion, reduction of fracture, stereotactic navigation, vertebroplasties of T5,6,7,9,10,11
Technique
The patient was brought to the operating room and correctly identified by name and medical record number by the surgical, nursing and anesthesia teams. Following placement of additional lines by the anesthetist, the patient was transferred over to the flat Jackson table and neurologic exam performed demonstrating ability to move his feet. He underwent general endotracheal anesthesia. Neuro monitoring signals were then placed and a baseline somatosensory evoked potential and motor evoked potentials were obtained. These were referenced as baseline signals. Fluoroscopy was used to identify the nature of the fracture alignment prior to manipulation. Once he was in position, the open Jackson table was placed over and all points were placed correctly with the chest roll placed at proximally of the level of the fracture to reduce. The patient was flipped so that he was now prone and the flat Jackson top removed. All points were again visually inspected. Another set of neuro monitoring potentials obtained demonstrating stability. Fluoroscopy was again used to appreciate the alignment which was suspected to be different, likely attributed to the prone position with only nominal malalignment in the inferior spine anterolisthesed. The intended incision was identified, cleaned, marked, prepped and draped in the usual sterile fashion and a final time-out performed. Using sharp and electrocautery dissection a long midline incision was made and carried down to the fascia. Dissection was kept in the suprafascial plane and hemostasis confirmed. Dissection was carried down an inferior spinous process of T10 and a reference frame clamped. At this point the table was draped and an intraoperative O arm spin performed and the images transferred for reconstruction and navigation intraoperatively. Anatomic landmarks were then confirmed. Using the navigation, the entry points for the T5, T6, T7, T9, T10 and T11 pedicles were identified. A navigated tap was used measuring 4.5 mm in the inferior half and 3.5 mm at the superior half. Using the same trajectories, 4.5 x 40 mm Stryker Everest MIXT screws were placed in T5, T6 and T7 and 5.5 x 45 mm screws were placed in T9, T10 and T11 for instrumented fusion. Another O arm spin was performed confirming screw placement. Great concern for the poor bone quality and the need for screw based fracture reduction, cement augmentation was felt appropriate to allow for screw reinforcement. At this point, Stryker cement was then mixed and 1 cc of bone cement were placed within each screw to augment the vertebral bodies. This was done under live fluoroscopy. Rods were then fashioned and passed from cephalad to caudad through the towers. Set screws were then placed and tightened in T5 through T7 and at T11. Under live fluoroscopy, reducing towers were used pull T8 fracture back into alignment with the towers of T9. Once these were in place, attempts were made to additionally compress the fracture however this resulted in further fish mouth appearance to the fracture and therefore was stopped. The fracture alignment returned and set screws were then placed to lock the system fully. The towers were removed and the bed copiously irrigated and attention turned to closure. A drain was placed and tunneled inferiorly. Final images were obtained and the incision closed with 3-0 Vicryl and 3-0 nylon. The patient was then flipped into the supine position, woken and extubated and taken to the recovery room in unchanged neurologic and cardiovascular condition. Throughout the procedure, SSEP and MEP all remained stable.
Estimated Blood Loss
Nominal
Findings
Satisfactory reduction and instrumentation
Postoperative Diagnosis
T8 fracture dislocation, Chance fracture
Operation
T5-T11 instrumented fusion, reduction of fracture, stereotactic navigation, vertebroplasties of T5,6,7,9,10,11
Technique
The patient was brought to the operating room and correctly identified by name and medical record number by the surgical, nursing and anesthesia teams. Following placement of additional lines by the anesthetist, the patient was transferred over to the flat Jackson table and neurologic exam performed demonstrating ability to move his feet. He underwent general endotracheal anesthesia. Neuro monitoring signals were then placed and a baseline somatosensory evoked potential and motor evoked potentials were obtained. These were referenced as baseline signals. Fluoroscopy was used to identify the nature of the fracture alignment prior to manipulation. Once he was in position, the open Jackson table was placed over and all points were placed correctly with the chest roll placed at proximally of the level of the fracture to reduce. The patient was flipped so that he was now prone and the flat Jackson top removed. All points were again visually inspected. Another set of neuro monitoring potentials obtained demonstrating stability. Fluoroscopy was again used to appreciate the alignment which was suspected to be different, likely attributed to the prone position with only nominal malalignment in the inferior spine anterolisthesed. The intended incision was identified, cleaned, marked, prepped and draped in the usual sterile fashion and a final time-out performed. Using sharp and electrocautery dissection a long midline incision was made and carried down to the fascia. Dissection was kept in the suprafascial plane and hemostasis confirmed. Dissection was carried down an inferior spinous process of T10 and a reference frame clamped. At this point the table was draped and an intraoperative O arm spin performed and the images transferred for reconstruction and navigation intraoperatively. Anatomic landmarks were then confirmed. Using the navigation, the entry points for the T5, T6, T7, T9, T10 and T11 pedicles were identified. A navigated tap was used measuring 4.5 mm in the inferior half and 3.5 mm at the superior half. Using the same trajectories, 4.5 x 40 mm Stryker Everest MIXT screws were placed in T5, T6 and T7 and 5.5 x 45 mm screws were placed in T9, T10 and T11 for instrumented fusion. Another O arm spin was performed confirming screw placement. Great concern for the poor bone quality and the need for screw based fracture reduction, cement augmentation was felt appropriate to allow for screw reinforcement. At this point, Stryker cement was then mixed and 1 cc of bone cement were placed within each screw to augment the vertebral bodies. This was done under live fluoroscopy. Rods were then fashioned and passed from cephalad to caudad through the towers. Set screws were then placed and tightened in T5 through T7 and at T11. Under live fluoroscopy, reducing towers were used pull T8 fracture back into alignment with the towers of T9. Once these were in place, attempts were made to additionally compress the fracture however this resulted in further fish mouth appearance to the fracture and therefore was stopped. The fracture alignment returned and set screws were then placed to lock the system fully. The towers were removed and the bed copiously irrigated and attention turned to closure. A drain was placed and tunneled inferiorly. Final images were obtained and the incision closed with 3-0 Vicryl and 3-0 nylon. The patient was then flipped into the supine position, woken and extubated and taken to the recovery room in unchanged neurologic and cardiovascular condition. Throughout the procedure, SSEP and MEP all remained stable.
Estimated Blood Loss
Nominal
Findings
Satisfactory reduction and instrumentation