Operative Flash-Dictation Neurosurgery Handbook

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Operative Dictations:

NEUROSURGERY

Chaim B. Colen, M.D., Ph.D.

COPYRIGHT © 2008

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Operative Dictation: Neurosurgery

Colen Publishing, LLC PO Box 35635 Grosse Pointe Woods, MI 48236 Author and Editor: Chaim B. Colen, M.D., Ph.D. Editorial Assistant: Roxanne E. Colen, PA-C COPYRIGHT © 2008 by Colen Publishing, LLC. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the author’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms and electronic data processing and storage. Some of the product names, patents and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Printed in the United States of America ISBN 10: 1-935345-03-6 ISBN 13: 978-1-935345-03-9 Note: Knowledge in medicine is constantly changing. The author has consulted sources believed to be reliable in the effort to provide information that is complete and in accord with the standards at the time of publication. However, in view of the possibility of human error by the author in preparation of this work, warrants that the information contained herein is in every respect accurate and complete and that the author is not responsible for any errors or omissions or for the results obtained from use of such information. The reader is advised to confirm the information contained herein with other sources. This is especially important in connection with new or infrequently used drugs. In such instances, the product information sheet included in the package with each drug should be reviewed.

Colen Publishing “Infinite possibilities to

learning…”

www.colenpublishing.com

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CONTENTS

Table of Contents CONTENTS ............................................................................................... iii CONTRIBUTORS ....................................................................................... vi DEDICATION ........................................................................................... vii PREFACE ................................................................................................ viii FORWARD ............................................................................................... ix OPERATIVE INSTRUMENTS ....................................................................... 1

PERFORATOR DRILL BITS/ BURRS ...................................................... 2 DURAL SEPARATORS .......................................................................... 2 HOOKS ................................................................................................ 3 HOOKS ................................................................................................ 3 DISSECTORS ........................................................................................ 4 KERRISSON RONGEUR ....................................................................... 4 SCISSORS ............................................................................................ 4 SCISSORS/ CLAMPS/ FORCEPS ........................................................... 5 ELEVATORS ......................................................................................... 6 ELEVATORS ......................................................................................... 6 ELEVATORS ......................................................................................... 7 SUCTION TIPS ..................................................................................... 7 FORCEPS ............................................................................................. 8 BAYONET FORCEPS ............................................................................ 8 BAYONET FORCEPS ............................................................................ 9 MICRO SCISSORS ................................................................................ 9 MICRO SCISSORS .............................................................................. 10 BIPOLAR BAYONET FORCEPS ........................................................... 10 SPECULUMS ..................................................................................... 11 RETRACTORS .................................................................................... 11 NERVE ROOT RETRACTORS .............................................................. 12

CRANIAL PROCEDURES ........................................................................... 14 CRANIAL DICTATIONS GUIDE ...................................................................... 15 BURR HOLE DRAINAGE FOR ....................................................................... 17 CHRONIC SUBDURAL HEMATOMA (SDH) EVACUATION ................................ 17 CRANIOTOMY FOR..................................................................................... 20 ACUTE SUBDURAL HEMATOMA (SDH) EVACUATION .................................... 20 CRANIOTOMY FOR .................................................................................... 23 ACUTE EPIDURAL HEMATOMA (EDH) EVACUATION ..................................... 23 DECOMPRESSIVE CRANIECTOMY FOR .......................................................... 26 INTRACRANIAL HEMORRHAGE/STROKE/ TRAUMATIC BRAIN INJURY ............... 26 CRANIOPLASTY ......................................................................................... 30

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OMMAYA RESERVOIR PLACEMENT .............................................................. 34 TRANSSPHENOIDAL HYPOPHYSECTOMY ....................................................... 38 CRANIOTOMY FOR MCA ANEURYSM CLIPPING ............................................ 42 STEREOTACTIC FRAMELESS ........................................................................ 48 BURR HOLE CRANIOTOMY FOR BIOPSY ....................................................... 48 STEREOTACTIC CRANIOTOMY FOR SUPRATENTORIAL BIOPSY ......................... 52 CRANIOTOMY FOR .................................................................................... 56 STEREOTACTIC TUMOR RESECTION WITH MAPPING AND MONITORING .......... 56 CRANIOTOMY WITH ORBITAL OSTEOTOMY .................................................. 62 PTERIONAL OSTEOPLASTIC CRANIOTOMY .................................................... 68 TRANSCORTICAL INTRAVENTRICULAR TUMOR RESECTION ............................. 74 CHIARI DECOMPRESSION ........................................................................... 79 STEREOTACTIC SUBOCCIPITAL CRANIECTOMY .............................................. 83 RETROSIGMOID CRANIOTOMY TRANSCONDYLAR APPROACH ......................... 88 GAMMA‐KNIFE STEREOTACTIC RADIOSURGERY ............................................ 93

FUNCTIONAL, EPILEPSY AND PAIN .......................................................... 96 EPILEPSY SURGERY STAGE I: LONG TERM MONITORING ELECTRODES PLACEMENT ............................................................................................. 97 EPILEPSY SURGERY STAGE II: PRE MOTOR CORTEX LESION RESECTION ........ 101 STAGE II EPILEPSY SURGERY: TEMPORAL LOBE LESION RESECTION .............. 107 MICROVASCULAR DECOMPRESSION .......................................................... 114 DEEP BRAIN STIMULATOR (DBS) LEAD PLACEMENT ................................... 118 DEEP BRAIN STIMULATOR (DBS) GENERATOR PLACEMENT ........................ 126 RHIZOTOMY: MEDIAL FACET BRANCH ....................................................... 129 CARPAL TUNNEL RELEASE ........................................................................ 132 ULNAR NERVE DECOMPRESSION .............................................................. 135 PERONEAL NERVE DECOMPRESSION ......................................................... 138 SPINAL CORD STIMULATOR PLACEMENT ................................................... 142 VAGAL NERVE STIMULATOR IMPLANTATION .............................................. 146

SHUNTING PROCEDURES ...................................................................... 150 VENTRICULO‐PERITONEAL SHUNT PLACEMENT .......................................... 151 LUMBAR PERITONEAL SHUNT PLACEMENT ................................................ 155 THIRD VENTRICULOSTOMY....................................................................... 158

SPINAL PROCEDURES ............................................................................ 163 SPINAL DICTATIONS GUIDE ...................................................................... 164 ANTERIOR CERVICAL DISCECTOMY AND FUSION ......................................... 165 CERVICAL CORPECTOMY ........................................................................... 174 CERVICAL LAMINECTOMY WITH LATERAL MASS ARTHRODESIS .................... 179 CERVICAL LAMINOPLASTY ........................................................................ 184 LAMINECTOMY FOR INTRAMEDULLARY SPINAL CORD TUMOR ..................... 188 LAMINECTOMY FOR EXCISION OF INTRADURAL EXTRAMEDULLARY SPINAL CORD

TUMOR .................................................................................................. 193 LUMBAR HEMILAMINECTOMY MICRODISCECTOMY ..................................... 198 LUMBAR LAMINECTOMY‐ BILATERAL ........................................................ 202 MINIMALLY INVASIVE: LUMBAR LAMINECTOMY DISCECTOMY ..................... 206

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PERCUTANEOUS DISCECTOMY .................................................................. 210 POSTERIOR LUMBAR INTERBODY FUSION .................................................. 213 REDO INSTRUMENTATION REMOVAL ......................................................... 218 THORACIC CORPECTOMY: LATERAL EXTRACAVITARY APPROACH .................. 224 THORACIC CORPECTOMY: TRANSTHORACIC APPROACH .............................. 231 X‐STOP .................................................................................................. 236

VASCULAR/ENDOVASCULAR ................................................................. 239 PROCEDURES ....................................................................................... 239

CAROTID ENDARTERECTOMY .................................................................... 240 CEREBRAL ANGIOGRAPHY ........................................................................ 244 CEREBRAL ANGIOGRAM WITH ANEURYSM COILING .................................... 248 CEREBRAL ANGIOGRAM WITH STENT‐ASSISTED ANEURYSM COILING ............ 254 CEREBRAL ANGIOGRAM WITH ARTERIO‐VENOUS MALFORMATION (AVM) EMBOLIZATION ....................................................................................... 260 ANGIOGRAM WITH CAROTID BALLOON ANGIOPLASTY AND STENT PLACEMENT

............................................................................................................. 266 MINOR PROCEDURES ........................................................................... 272

ARTERIAL LINE PLACEMENT ..................................................................... 273 LUMBAR SPINAL PUNCTURE ..................................................................... 275 LUMBAR DRAIN PLACEMENT .................................................................... 278 VENTRICULOSTOMY PLACEMENT .............................................................. 281 VERTEBROPLASTY/KYPHOPLASTY .............................................................. 284

APPENDIX ............................................................................................ 288 ABBREVIATIONS ................................................................................... 289

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CONTRIBUTORS

FACULTY REVIEWERS Alan Scarrow, M.D., J.D. St. John's Clinic - Neurosurgery 1965 S. Fremont Ste. 130 Springfield, MO 65804 Gregory Przybylski, M.D. Director of Neurosurgery New Jersey Neuroscience Institute JFK Medical Center, Edison, New Jersey

RESIDENTS Raul Olivera, M.D. Division of Neurosurgery Department of Surgery Saint Louis University School of Medicine St. Louis, MO 63110 Clemens M. Schirmer, M.D. Department of Neurosurgery Tufts New England Medical Center Boston, MA

MEDICAL STUDENTS

Alexandria Conley Wayne State University Detroit, MI Christopher E. Lai Wayne State University Detroit, MI Brett Justin Mollard Wayne State University Detroit, MI Adam Robin Wayne State University Detroit, MI

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DEDICATION I dedicate this effort to my ever-supportive wife Roxanne, daughter Emily and son Joshua whose love, patience and encouragement allowed me to achieve the completion of this book. My Motto: If you love yourself, you will love your patient and your patient will love you. Live, Love and leave a Legacy. Chaim Benjoseph Colen M.D., Ph.D. 09/03/02

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PREFACE

Concern for man and his fate must always form the chief interest of all technical endeavors… Never forget this in the midst of your diagrams and equations.

Albert Einstein

Operative dictations are an essential part of the neurosurgical career. Excellent operative dictations can be likened to "Fidelio" the beautiful Beethoven masterpiece. Each word must flow on a musical note; translating 3‐dimensional neuroanatomic melodies into a verbalized anatomic clinico‐surgical masterpiece. On the other hand, a poor operative dictation can be perceived as the lack of clinico‐scientific knowledge or poor comprehension of the operation that was just performed.

Operative Dictations: Neurosurgery is meant to provide the basic musical notes needed to come closer to achieving a verbalized operative "Beethoven masterpiece". It provides illustrations of basic operative instruments and skeleton operative dictations with their respective CPT codes; to assist the novice surgeon in becoming a verbally skilled surgeon. Practice makes perfect and by rehearsing your operation in a well structured, systematic and cohesive fashion, you will improve your operative efficiency and medico‐legal sustaining jargon; a prerogative in our day.

In no way is this book comprehensive enough to cover all operative dictations performed in neurosurgery; rather it is meant to be a basic guide to allow the novice surgeon the scaffolding needed to dictate a basic straight forward case. The most common cases are described in a consistent format, with bolded statements meant to reinforce the most important segments from the medico‐legal standpoint. There are many times during our operative careers that we deviate from the norm; this uniqueness should be dictated on a per‐case‐basis. May this book benefit all residents and junior staff, with the ultimate goal of improving our verbalized legacy of Neurosurgery.

Chaim B. Colen 2008

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FORWARD Most of us went into neurosurgery because we had a passion for clinical tasks of our profession – listening to patients, thinking about how to help them, performing the surgery, and finding out if our efforts have helped them. I am confident very few of us have a similar passion for the dictation, documentation, and paperwork that necessarily accompany those more pleasant clinical tasks. Nonetheless accurately recording what we do in our clinical and surgical work is not just a good medico‐legal practice, it’s simply good medicine. In this book, Dr. Colen has made the task of documenting our surgical work much easier. What follows are detailed operative notes and CPT coding for the typical surgical work we do involving spine, tumor, vascular, functional, and stereotactic procedures. This will allow readers to take these templates, modify them to their own unique variations for an individual procedure, and incorporate them into the patient’s medical record. This should be particularly helpful to those who are new to the responsibilities of medical and surgical documentation. In publishing this work, Dr. Colen is helping us as neurosurgeons spend more time doing the things we love, and less time recording how we did them. It is an admirable ambition. Alan M. Scarrow, M.D., J.D. Chairman, Section of Neurosurgery St. John’s Clinic Springfield, Missouri

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OPERATIVE INSTRUMENTS

L'OPÉRATION DU TRÉPAN

Encyclopédie Ou Dictionnaire Raisonné Des Sciences, Des Arts Et Des Métiers, 1772

Trepanation is one of the earliest cranial operations performed by man. It was carried out for both medical reasons and mystical practices for a long time: evidence of trepanation has been found in prehistoric human remains from Neolithic times onwards. The above artwork is from an 18th century French illustration of trepanation. People believed the practice would cure epileptic seizures, migraines, and mental disorders. In prehistoric times, trepanation was thought to cure diseases by letting evil spirits escape. The bone that was trepanned was kept by the prehistoric people and worn as charms to keep evil spirits away.

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HOOKS

HOOKS

1 2 3 4 5 6 7

1 532 6 74

1. Sachs dural hook 2. Cushing dural hook 3. Frazier dural hook 4. Lahey clinic dural hook 5. Strully dural twist hook 6. Dandy nerve hook 7. Adson dural hook

1. Hoen nerve hook, straight 2. Hoen nerve hook, angled 3. Smithwick hook & dissector 4. Murphy ball hook 5. Cushing gasserian ganglion hook, blunt 6. Smithwick button hook, blunt 7. Davis nerve separator/spatula

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DISSECTORS

KERRISSON RONGEUR

SCISSORS

1 2 3 4 5 6 7 8

1. Penfield dissector, #1 2. Penfield dissector, #2 3. Penfield dissector, #3 4. Penfield dissector, #4 5. Penfield dissector, #5 6. Double dissector, sharp/blunt 7. Woodson elevator/spatula double end 8. Woodson separator/packer, double end

1. Kerrisson rongeur

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PTERIONAL OSTEOPLASTIC CRANIOTOMY DATE OF SURGERY: SURGEON: Dr. X ASSISTANT: Dr. Y PREOPERATIVE DIAGNOSIS: (Right/Left) clinoidal mass. POSTOPERATIVE DIAGNOSIS: (Right/Left) clinoidal (meningioma). PROCEDURES PERFORMED: 1. Stereotactic (Right/Left) pterional osteoplastic

craniotomy with resection of clinoidal/sphenoid wing mass.

2. Intraoperative use of microscope for microdissection. 3. Intraoperative electrophysiological monitoring with SSEPs

and motor evoked potentials. ANESTHESIA: GETA. ESTIMATED BLOOD LOSS: (XX) cc. FINDINGS: Frozen section was consistent with ___. DRAINS: (JP/Blake) drain. COMPLICATIONS: None. DISPOSITION: Stable to the PACU.

CPT Coding 61592 Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra or intradural elevation of temporal lobe 61795 Stereotactic computer‐assisted volumetric (navigational) procedure, intracranial or spinal (List separately in addition to primary procedure) 69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)

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INDICATIONS FOR THE PROCEDURE HISTORY: (Mr./Ms.) (Pt. Name) is a (Pt. Age) year old (Male/Female) who presents with signs and symptoms consistent with a clinoidal/sphenoid wing mass (double vision, blurry vision, cranial nerve palsy). The goal of the operation was optic and cranial nerve decompression. DIAGNOSTIC STUDIES: MRI brain showed ___. SURGICAL RISKS: The patient (family/N.O.K./P.O.A.) was well apprised of all objectives, benefits, risks and potential complications of the procedure, including but not limited to: worsening of current status, the possible need for further procedures, the risk of infection, headaches, CSF leak, seizures, hemorrhage, stroke, loss of language function, paralysis, coma and even death. Informed consent was obtained and secured in the chart after the patient (family/N.O.K./P.O.A.) voiced understanding of these risks and decided to proceed with the operation.

DESCRIPTION OF THE PROCEDURE: The patient was transferred to the operating room. (He/She) was given preoperative prophylactic IV antibiotics. ANESTHESIA: The patient was sedated and intubated without difficulty by the anesthesia service. Eyes were taped shut after ointment was applied to prevent corneal abrasion. A Bair Hugger was placed over the exposed lower body to maintain control of core body temperature. A Foley catheter was inserted. POSITIONING: A Mayfield head clamp was applied. The patient was positioned supine with the head turned approximately (XX) degrees to the (Right/Left) with very mild extension. All pressure points were carefully padded. The hair was clipped over the area where (He/She) was to undergo the incision. Pre‐prepping was done with (chlorhexidine solution, alcohol). The electrophysiology monitoring team inserted needles in their proper locations and baseline SSEPs and motor evoked potentials were

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obtained. Stereotactic CT/MRI was done on the morning of the surgery and the images were transferred to the neuronavigational system. Next, three‐dimensional images were reconstructed. The patient underwent co‐registration of the preoperative stereotactic CT/MRI with (His/Her) surface landmarks. Accuracy was within 2mm. Vital structure landmarks including the (motor area/speech area/superior sagittal sinus) were identified and mapped out. The planned craniotomy was outlined. OPERATIVE TECHNIQUE: The patient was prepped and draped in standard sterile fashion. IF FAT GRAFT WILL BE USED: The (Right/Left) lower abdomen was prepped and draped as well in standard sterile fashion. Local anesthesic was infiltrated along the line of planned and marked skin incision. A (Right/Left) fronto‐temporal (C‐shaped, question mark) incision was opened sharply with a # (XX) scalpel blade to the level of the periosteum. Subcutaneous dissection was performed sharply with Metzenbaum scissors, preserving the superficial temporal artery and its branches. Interfascial dissection was completed along the superficial temporalis muscle fascia to preserve the frontalis branch of the facial nerve. The skin flap was reflected anteriorly leaving the temporalis muscle in place. Osteoplastic craniotomy was performed by leaving the temporalis muscle and periosteum attached to the temporal bone. The frontal bone periosteum was elevated parallel to the orbital ridge approximately (X) cm superior to the ridge and followed along the orbital zygomatic arch. Care was taken to identify and preserve the supraorbital nerve at the supraorbital (notch/foramen). Elevation of the periosteum was continued along the zygomatic arch from medial to lateral. A small portion of the temporalis muscle was dissected from the supero‐anterior bone and the infero‐posterior bone. The

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high speed (electric/ pneumatic) drill was utilized to make (XX) craniotomy burr holes; one at the pterion (“MacCarty keyhole” ‐keyhole burr hole) the second at the squamous temporal and the third at the superior medial frontal bone (posterior temporal). The dura was dissected free underneath all burr holes. With the B1 bit and footplate, the burr holes were interconnected and a craniotomy completed. The osteoplastic bone flap was freed from the dura with #3 Penfields and was reflected anterolaterally still attached to its temporalis pedicle and held in place with fish‐hooks. The dura was visualized (intact/with durotomy). Hemostasis was achieved utilizing a combination of bipolar electrocautery and absorbable gelatin compressed sponge (Gelfoam). The wound was irrigated until clear. The dura was opened in a (C‐shape, S‐shape) fashion. (Mannitol 25gm IV was given by the anesthesia team). Several (X)‐0 non‐absorbable braided polyamide suture (Nurolon) tacking sutures were used to elevate the dura anteriorly. The Buddy halo was attached to the Mayfield headholder. At this point the operative microscope was draped with sterile drapes and brought into the operative field. With microdissection technique the Sylvian fissure was opened and the dural based tumor came into view. Minimal brain retraction was required. Hemostasis was achieved utilizing bipolar electrocautery and absorbable gelatin compressed sponge (Gelfoam). [Absorbable gelatin compressed sponge (Gelfoam) was neatly tucked circumferentially around the craniotomy just underneath the dura to prevent blood from reaching other areas of the brain.] The (Right/Left) optic nerve was identified and the opticocarotid cistern opened to allow CSF egress and brain decompression. IDENTIFICATION OF STRUCTURES: The internal carotid artery, optic nerve and third cranial nerve were identified.

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FINDINGS: (intra/extracavernous tumor compression of cranial nerves, arterial constrictions by tumor). The lesion was noted to be (color, swelling, consistency, [well‐defined, ill‐defined] planes, dural attachments). WHAT WAS DONE: Microdissection with tumor resection, further drilling of the anterior clinoid, unroofing the third cranial nerve, decompression of the superior orbital fissure contents, mobilizing the dura propria from the lateral wall of the cavernous sinus. Tumor extirpation was performed through the opticocarotid, carotid–oculomotor, and prechiasmatic spaces. Attention was paid to avoid violating the perforating arteries situated in the opticocarotid triangle. A nerve hook was used to carefully dissect tumor near the optic foramen. [To avoid risk of devascularizing the optic nerve, further attempts of removing this tiny bit of tumor were abandoned]. Careful bipolar electrocautery was used to achieve hemostasis on all dural edges and the dura was stripped from the clinoid process and the medial most part of the sphenoid wing. The wound was irrigated until clear. Verification of volumetric resection was performed with the neuronavigational probe. The tumor was sent to pathology. Having accomplished the goal of decompression of the optic nerve, superior orbital fissure and cranial nerves, we proceeded with harvesting of a fat graft from the abdomen. IF FAT WILL BE USED: An incision was made in the anterior (Right/Left) lower quandrant part of the abdomen. Fat was obtained and hemostasis promptly achieved. The fascia was approximated with (X)‐0 polyglactin synthetic absorbable suture (Vicryl). The skin was then closed with (nylon suture, skin‐glue, steri‐strips, surgical staples). A sterile dressing was placed over the closed wound.

The fat graft was placed between the inferior aspect of the optic nerve, the carotid artery and the superior orbital fissure. The optic nerve was gently separated in this fashion

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from the parasellar region in anticipation of potential stereotactic radiosurgery at a later date. The field was irrigated clear. The dura was closed in a water‐tight fashion with interrupted (X)‐0 non‐absorbable braided polyamide suture (Nurolon). The dural defect created at the orbital apex from removal of the dura from the anterior clinoid process was covered with fat graft to prevent CSF leak. The bone flap was replaced and affixed with miniplates and screws. (Cranioplasty: The cranial defect was reconstructed using a synthetic cranioplasty implant.) The wound was irrigated with antibiotic solution. The temporalis muscle was reapproximated with (X)‐0 polyglactin synthetic absorbable suture (Vicryl) and secured onto the bone flap. The galea was reapproximated utilizing inverted interrupted (X)‐0 polyglactin synthetic absorbable suture (Vicryl). The skin was then closed with (nylon suture, skin‐glue, steri‐strips, surgical staples). A sterile head dressing was placed over the closed wound. All needle counts, sponge counts and instrument counts were correct at the end of the case times two. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. Dr. X was present during the critical portions of this case.

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FUNCTIONAL, EPILEPSY AND PAIN

1. Epilepsy Surgery Stage I: Long Term Monitoring Electrodes Placement.

2. Epilepsy Surgery Stage II: Premotor Cortex Lesion Resection.

3. Epilepsy Surgery Stage II: Temporal Lobe Lesion Resection.

4. Microvascular Decompression. 5. Deep Brain Stimulator Lead Placement. 6. Deep Brain Stimulator Generator Placement. 7. Rhizotomy: Medial Facet Branch. 8. Carpal Tunnel Release. 9. Ulnar Nerve Decompression. 10. Peroneal Nerve Lysis. 11. Spinal Cord Stimulator Placement. 12. Vagal Nerve Stimulator Implantation.

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SHUNTING PROCEDURES

1. Ventricular Peritoneal Shunt Placement 2. Lumbar Peritoneal Shunt Placement 3. Endoscopic Third Ventriculostomy

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SPINAL PROCEDURES Spinal Dictations Guide

1. Anterior Cervical Discectomy and Fusion (ACDF) 2. Anterior Lumbar Interbody Fusion (ALIF) 3. Cervical Corpectomy 4. Cervical Laminectomy with Lateral Mass Arthrodesis 5. Cervical Laminoplasty 6. Extreme Lateral Interbody Fusion (XLIF) 7. Laminectomy for Intramedullary Spinal Tumor 8. Laminectomy for Excision of Intradural

Extramedullary Spinal Tumor 9. Lumbar Hemilaminectomy and Microdiscectomy 10. Lumbar Laminectomy‐ Bilateral 11. MIS Laminectomy 12. Percutaneous Discectomy 13. Posterolateral Interbody Fusion (PLIF) 14. Redo Instrumentation Removal 15. Thoracic Corpectomy Lateral Extracavitary

Approach 16. Thoracic Corpectomy Transthoracic Approach 17. X‐Stop

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SPINAL DICTATIONS GUIDE In Neurosurgery there are a lot of spinal procedures with a lot of different codes. These codes are constantly changing. When using this section remember to keep in mind that you should consult an official CPT book for accurate coding for purposes of reimbursement. Some procedures are performed with electrophysiological monitoring (see Cervical Laminoplasty for example). The CPT coding is provided here for your quick review. In cases where fluoroscopic guidance is used during the spinal procedure consider using the following CPT codes: In cases where bone marrow aspirate is used during the spinal procedure consider using the following CPT code:

CPT Coding 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95926 Short‐latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95925 Short‐latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs

CPT Coding 20986 Computer‐assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on intraoperatively obtained images (eg, fluoroscopy, ultrasound) (List separately in addition to code for primary procedure) 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

CPT Coding 38220 Bone marrow; aspiration only

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ANTERIOR CERVICAL DISCECTOMY AND

FUSION DATE OF SURGERY: SURGEON: Dr. X ASSISTANT: Dr. Y PREOPERATIVE DIAGNOSIS: C(LEVEL)‐C(LEVEL) radiculopathy and herniated cervical disc. POSTOPERATIVE DIAGNOSIS: C(LEVEL)‐C(LEVEL) radiculopathy and herniated cervical disc. PROCEDURE PERFORMED: 1. C(LEVEL)‐C(LEVEL) anterior cervical discectomy with decompression of spinal cord and osteophytectomy.

2. C(LEVEL)‐C(LEVEL) anterior interbody arthrodesis. 3. C(LEVEL)‐C(LEVEL) insertion of interbody allograft. 4. Microsurgical techniques, requiring use of operating microscope for discectomy and osteophytectomy.

5. C(LEVEL)‐C(LEVEL) anterior plate and screws. 6. Fluoroscopic guidance for localization and instrumentation.

CPT Coding 20931 Allograft for spine surgery only; structural (List separately in addition to code for primary procedure) 22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) 22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure) 22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace

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ANESTHESIA: GETA. ESTIMATED BLOOD LOSS: (XX) cc. FINDINGS: DRAINS: (JP/Blake) drain. COMPLICATIONS: None. DISPOSITION: Stable to the PACU INDICATIONS FOR THE PROCEDURE Mr./Ms. (Pt. Name) is a (Pt. Age) year old (Male/Female) who presents with signs, symptoms and radiographic evidence of (Right/Left) neck pain radiating into (His/Her) (Right/Left) arm in a C(LEVEL) dermatomal pattern. DIAGNOSTIC STUDY: MRI cervical spine showed___. (He/She) had failed conservative treatment (physical therapy, pain medication, epidural steroids) and (His/Her) symptoms continued to progress. Given the progression of the symptoms, it was decided to proceed with the decompression of the herniated disc and osteophyte complex at C(LEVEL). SURGICAL RISKS: The patient (family/ N.O.K./ P.O.A.) were apprised of all objectives, benefits, risks and potential complications of the procedure, including but not limited to: worsening of current status, the possible need for further procedures, the risk of infection, headaches, CSF leak, possible spinal cord injury resulting in paralysis, infection, neck hematoma and hoarseness of voice, injury to major vessels causing hemorrhage, stroke, loss of language function, coma and even death. Informed consent was obtained and secured in the chart after the patient

CPT Coding (Cont.) 69990 Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

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(family/ N.O.K./ P.O.A.) voiced understanding of these risks and decided to proceed with the operation.

DESCRIPTION OF THE PROCEDURE The patient was transferred to the operating room. (He/She) was given preoperative prophylactic IV antibiotics. ANESTHESIA: The patient was sedated and intubated without difficulty by the anesthesia service. Eyes were taped shut after ointment was applied to prevent corneal abrasion. A Bair Hugger was placed over the lower body to maintain control of core body temperature. A Foley catheter was inserted. POSITIONING: The patient was placed in the supine position with a gel roll underneath (His/Her) head. All pressure points were carefully padded. OPERATIVE TECHNIQUE: The skin was prepped and draped in the standard surgical fashion and the area marked with a marking pen utilizing standard landmarks such as midline and cricoid cartilage. A transverse neck incision was performed opposite the C(LEVEL)‐C(LEVEL) level using a # (XX) scalpel blade after infiltration with (XX) % Marcaine with epinephrine. The incision was deepened through platysma muscle and the edges undermined using sharp dissection. Hemostasis was obtained utilizing Bovie electrocautery as well as the bipolar forceps. Further blunt and sharp dissection was carried down in the plane medial to the omohyoid muscle. Blunt dissection was performed medial to the carotid sheath down to the anterior longitudinal ligament in front of the spine. The C‐arm fluoroscopy unit was draped with sterile drapes and brought into the operative field. The level of C(LEVEL)‐C(LEVEL) was confirmed by placing a marker needle and fluoroscopic x‐ray. The longus coli muscle was undermined with monopolar electrocautery on either side until the uncovertebral joints were exposed. Self‐retaining retractors

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VASCULAR/ENDOVASCULAR PROCEDURES

1. Carotid Endarterectomy 2. Cerebral Angiography 3. Cerebral Angiogram with Aneurysm Coiling 4. Cerebral Angiogram with Stent‐assisted Aneurysm

Coiling 5. Cerebral Angiogram with AVM embolization 6. Angiogram with Carotid Balloon Angioplasty and

Stent Placement

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CEREBRAL ANGIOGRAPHY

DATE OF PROCEDURE: RADIOLOGIST/SURGEON: Dr. X ASSISTANT: Dr. Y PREOPERATIVE DIAGNOSIS: (Subarachnoid hemorrhage, carotid stenosis). POSTOPERATIVE DIAGNOSIS: (Subarachnoid hemorrhage, carotid stenosis). PROCEDURES PERFORMED: 1. Bilateral (vessel) angiogram‐cervical. 2. Bilateral (vessel) angiogram‐cerebral. 3. Rotational 3D (Right/Left) (vessel) angiogram. 4. Bilateral vertebral artery angiogram‐bilateral. 5. (Right/Left) common femoral artery angiogram. 6. Deployment of a (X)‐French Angio‐Seal within the right

femoral artery. ANESTHESIA: IV sedation with local anesthesia. ESTIMATED BLOOD LOSS: (XX) cc. FLUORO TIME: (XX) minutes and (XX) seconds. CONTRAST: Intravenous contrast agent (XX) cc. FINDINGS:

CPT Coding 75676 Angiography, carotid, cervical, unilateral, radiological supervision and interpretation 75671 Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation 75685 Angiography, vertebral, cervical, and /or intracranial, radiological supervision and interpretation 75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure)

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1. Report AVM, aneurysm remnants if clipped, vessel stenosis. 2. Report arterial, capillary, and venous opacification on all angiographic runs. COMPLICATIONS: None. DISPOSITION: Stable to the PACU.

INDICATIONS FOR THE PROCEDURE HISTORY: (Mr./Ms.) (Pt. Name) is a (Pt. Age) year old (Male/Female) with signs, symptoms and radiographic evidence of (Right/Left) [(Acom, Pcom, MCA, Basilar tip) aneurysm] or [carotid artery stenosis]. DIAGNOSTIC STUDY: MRI/CT/CTA/MRA brain showed ___. PROCEDURE RISKS: The patient (family/N.O.K./P.O.A.) was well apprised of all objectives, benefits, risks and potential complications of the procedure, including but not limited to: worsening of current status, the possible need for further procedures, the risk of infection, seizures, hemorrhage, stroke, loss of language function, paralysis, coma and even death. Informed consent was obtained and secured in the chart after the patient (family/N.O.K./P.O.A.) voiced understanding of these risks and decided to proceed with the procedure.

DESCRIPTION OF THE PROCEDURE The patient was transferred to the angiography suite. (He/She) was given preoperative prophylactic IV antibiotics. ANESTHESIA: The patient was given IV sedation by the anesthesia team. POSITIONING: The patient was placed in the supine position on the angio table. The groins were prepped and draped bilaterally in the usual sterile fashion. TECHNIQUE: The pulse of the common femoral artery was felt on the (Right/Left) groin and the overlying skin was infiltrated with (XX) % lidocaine. A stiff micropuncture set was utilized to gain access to the vessel. Pulsatile bright red

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MINOR PROCEDURES

1. Arterial Line Placement 2. Lumbar Spinal Puncture 3. Lumbar Drain Placement 4. Ventriculostomy Placement 5. Vertebroplasty/ Kyphoplasty

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APPENDIX Hydrogel dural sealant (DuraSeal) Oxidized cellulose absorbable hemostat (Surgicel) Synthetic cotton absorbant sponge (Cottonoid) Polyglactin synthetic absorbable suture (Vicryl) Non‐absorbable braided polyamide suture (Nurolon) Absorbable gelatin compressed sponge (Gelfoam) Microfibrillar collagen hemostat (Avitene) Poliglecaprone 25 (Monocryl) Adhesive skin closure (Steri‐Strips) Synthetic non‐absorbable polypropylene suture (Prolene)

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ABBREVIATIONS ACA = Anterior cerebral artery Acom = Anterior communicating artery AP = Anterior‐Posterior BMP = Bone morphogenic protein C = Cervical CSF = Cerebrospinal fluid CT = Computed tomography CT = Computed tomographic angiography CUSA = cavitron ultrasonic aspirator GETA = General endotracheal anesthesia L = Lumbar MEP = Motor‐evoked potentials MCA = Middle cerebral artery MRA = Magnetic resonance angiography MRI = Magnetic resonance imaging NOK = Next of kin PCA = Posterior cerebral artery Pcom = Posterior communicating artery POA = Power of attorney S = Sacral SSEP = Somotosensory‐evoked potentials T = Thoracic

Operative Flash-Dictation Neurosurgery Handbook

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