Exam 12: Nervous System

Case -T12-1C DISCHARGE SUMMARY LOCATION: Inpatient, Hospital PATIENT: Rebecca Sole ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD REASON FOR ADMISSION: Pain going down her left leg She had an MRI (magnetic resonance imaging) done that showed a large disc at L4-5 (fourth lumbar vertebra-fifth) on the left. She had not responded to conservative measures. She is a truck driver. EXAM: Chest: Clear. Cardiovascular exam: No murmurs. Abdomen: Soft. I saw her in the office. She continued to have pain, which was refractory to conservative measures. HOSPITAL COURSE: The patient underwent a laminotomy, foraminotomy, and removal of disc at L4-5. Her postoperative course was uneventful. The wound is clean. She is discharged to convalesce at home. FINAL DIAGNOSIS: Herniated disc L4-5 on the left PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc T12-1C: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -AUDIT REPORT T12.1 OPERATIVE REPORT, RE-DO LAMINOTOMY General LOCATION: Inpatient, Hospital PATIENT: Sarah Malone ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Herniation of L4-5 on the right POSTOPERATIVE DIAGNOSIS: Herniation of L4-5 on the right PROCEDURE PERFORMED: Re-do laminotomy, foraminotomy, L4-5 on the right ANESTHESIA: General PROCEDURE: Under general anesthesia, the patient was placed in the prone position. The back was prepped and draped in the usual manner. An incision was made extending through subcutaneous tissue. The lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The L4-5 interspace was localized via x-ray. We enlarged the laminotomy and foraminotomy, saw the extruded fragment, and removed it. We entered the disc space and removed much degenerating material. We decompressed the nerve root, satisfied there were no other free fragments. I irrigated the wound well. I put a Hemovac drain in the wound and closed the wound in layers utilized double-knotted 0 chromic on the lumbodorsal fascia, 0 Vicryl and 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room. PATHOLOGY REPORT LATER INDICATED: Intervertebral disc fragments, L4-L5 T12.1: SERVICE CODE(S): 63030_________________ ICD-10-CM DX CODE(S): M51.9___________ INCORRECT/MISSING CODE(S): ________________________________________

Case -T12-1A OPERATIVE REPORT, LAMINECTOMY AND FORAMINOTOMY LOCATION: Inpatient, Hospital PATIENT: Rebecca Sole ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Herniated disc, L4-5 on the left POSTOPERATIVE DIAGNOSIS: Same-lumbar disc, L4-5 (fourth lumbar vertebra-fifth) on the left PROCEDURE PERFORMED: Laminectomy, foraminotomy, and removal of disc ANESTHESIA: General PROCEDURE: Under general anesthesia, the patient was placed in the prone position. The back was prepped and draped in the usual manner. An incision was made in the skin, extending through subcutaneous tissue. Lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The interspace was localized via x-ray. A general laminotomy and foraminotomy were performed. We got onto the L4-5 interspace, saw the extruded disc, removed the fragments, entered the disc space, and cleaned out the disc space. There were fragments on the body of L5. There were fragments incarcerating the nerve root. I removed these, freed up the nerve root, took out all the disc fragments, and irrigated the wound well. Satisfied that I had decompressed the root well, I then put a Hemovac drain in the wound and closed the wound in layers, utilizing double-knotted 0 chromic on the lumbodorsal fascia with 0 Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to PAR (postanesthesia recovery). T12-1A: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T12-1B RADIOLOGY REPORT, LUMBAR SPINE This is the radiology service provided for the T12-1A report. LOCATION: Inpatient, Hospital PATIENT: Rebecca Sole ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD RADIOLOGIST: Grey Lonewolf, MD EXAMINATION OF: Lumbar spine CLINICAL SYMPTOMS: Laminectomy in OR (operating room) TWO VIEWS, LUMBAR SPINE: FINDINGS: This study is presented for review at 1 PM on Monday. Comparison views are not available for numbering purposes. It will be presumed for purposes of this study that there are five true lumbar vertebrae. Surgical instruments are present pointing to the posterior aspects of L5 and S1. Degenerative change of the spine is seen. T12-1B: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T12-2B PATHOLOGY REPORT LOCATION: Inpatient, Hospital PATIENT: Kenny Jetty ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PATHOLOGIST: Grey Lonewolf, MD CLINICAL HISTORY: Lower back pain due to herniated disc SPECIMEN RECEIVED: Disc, lumbar 4-5 GROSS DESCRIPTION: Submitted in formalin, labeled with the patient's name and "disc lumbar 4-5," are multiple fragments of ragged tan tissue measuring 7 3.5 1 cm (centimeter) in aggregate. Representative fragments are in one cassette. MICROSCOPIC DIAGNOSIS: Intervertebral disc, L4-5, discectomy: Fibrocartilaginous intervertebral disc fragments. T12-2B: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T12-2C OPERATIVE REPORT, SUBDURAL HEMATOMA This is not the same patient as in T12-2B. LOCATION: Inpatient, Hospital PATIENT: Robert Vobr ATTENDING PHYSICIAN: Ronald Green, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Subdural hematoma, traumatic POSTOPERATIVE DIAGNOSIS: Subdural hygroma, traumatic ANESTHESIA: Local; standby PROCEDURE: The patient's head was prepped and draped in the usual manner. An incision was made in the frontal left and left posterior parietal area. The skin was incised. Retractor was placed. Bone was isolated. Perforator was utilized. Burr hole was made, and the dura was incised and coagulated. Clear CSF (cerebrospinal fluid) exuded. This was a subdural hygroma. The brain was deep to the subdural hygroma. We placed two Penrose drains and then closed the wounds with 2-0 Vicryl on the galea with surgical staples on the skin. Dressing was applied. The patient was discharged to recovery. T12-2C: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -AUDIT REPORT T12.2 OPERATIVE REPORT, CERVICAL FX REPAIR AND HALO VEST PLACEMENT LOCATION: Inpatient, Hospital PATIENT: Terry Rake ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Unstable C4 fracture with deformity of the spine POSTOPERATIVE DIAGNOSIS: Unstable C4 fracture with deformity of the spine PROCEDURE PERFORMED: 1. Halo vest placement. 2. Posterior segmental fixation C3 to C5 with Halifax clamps. 3. Open repair of the cervical fracture (first-listed procedure). 4. Fusion of the posterior cervical spine from C3 to C5 utilizing one autograft and an iliac crest graft. 5. Evoked potential monitoring. ANESTHESIA: General endotracheal PROCEDURE: The patient was taken to the OR and placed under general anesthesia. After the patient was intubated, the patient was placed in a four-pin halo vest. This was accomplished by maintaining in-line cervical traction using standard technique and chest rolls. The posterior cervical region and the area surrounding the iliac crest were then shaved, prepped for harvest, and draped in sterile fashion. The iliac crest was harvested first through a standard incision. Then a split-thickness graft was harvested, making sure a large amount of cancellous bone was included in the harvest. The harvest sites were then closed in layers, and hemostasis was ensured. The posterior cervical region was then incised, and sharp dissection was carried down through the subcutaneous tissue. The fascia was then dissected from C3 through C5. This was done very cautiously and carefully. Then the superior aspect of the hemilamina of C5 was carefully exposed with curettes. Halifax clamps were then attached from C3 through C5. The area of the fracture of disc C4 was seen. The Halifax clamp construct was assembled and was noted to be secure. The lamina was then decorticated with a cutting burr, and the cancellous and cortical bones were used to finish the posterior fusion. Halifax clamps ensured the correct alignment of the slight deformity. Throughout the procedure evoked potential monitoring was performed. Hemostasis was achieved, and patient only had minimal blood loss. The wound was then closed in layers, and the skin was stapled with surgical staples. T12.2: SERVICE CODE(S): 22326, 22600, 22614-51, 20900-51, 20938-51, 22842-51, 95925 ICD-10-CM DX CODE(S): S12.300, M43.9___ INCORRECT/MISSING CODE(S): ________________________________________

Case -T12-2A RECORD OF OPERATION, LAMINOTOMY AND FORAMINOTOMY LOCATION: Inpatient, Hospital PATIENT: Kenny Jetty ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Herniated disc, L4-5 (fourth lumbar vertebra-fifth) on the left POSTOPERATIVE DIAGNOSIS: Herniated disc, L4-5 on the left PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of extruded disc ANESTHESIA: General PROCEDURE: Under general anesthesia, the patient was placed in a prone position, and the back was prepped and draped in the usual manner. An incision was made in the skin and extended through subcutaneous tissue. The lumbosacral fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The interspace was localized via x-ray. We then performed a generous laminotomy with the Kerrison rongeurs between L4-5. We did a partial facetectomy and got to the extruded disc by retracting on the nerve root. The disc had perforated through the annulus. We removed the disc material, entered the disc space, removed much degenerating material from the L4-5 interspace, went across the midline, and went laterally; I was satisfied I had decompressed the disc space well. I was able to pass a hockey stick down the foramen and across the midline. The wound was well irrigated. A Hemovac drain was placed into the wound. The wound was then closed in layers, utilizing double knotted 0 chromic on the lumbodorsal fascia with 0 Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to recovery. PATHOLOGY REPORT LATER INDICATED: See T12-2B. T12-2A: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________