Case -AUDIT REPORT T12.2 OPERATIVE REPORT, CERVICAL FX REPAIR AND HALO

Essay

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): ________________________________________