Preoperative Diagnosis:
1. Compartment syndrome paraspinal
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Postoperative Diagnosis: same as above
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Procedure(s):
1. Stryker compartment measuring
2. Fascia compartment release left and right dorsal paraspinal muscle
3. Debridement of dead muscle (deep)
4. Woundvac placmeent

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OPERATIVE COURSE:

The patient was brought into the Operating Room and upon reaching the
Operating Room, the patient underwent general anesthesia without any
complications.
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Next, I identified the skin marking and a time out was performed. The
patient was prepped and draped in the usual sterile fashion. Antibiotics
were present. DVT prophylaxis were present.
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We checked compartment pressure. The left was 90 mmhg and 85 mg while diastolic pressure was 75 mmhg.
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The right was 40 and 35 mm Hg.
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Next, the skin was incised. Two paraspinal incision were made. The left we got the fascia. We released the fascia and the muscle did swell somewhat. We kept releasing fascia till we were confident the muscle was released. We check the muscle, the deep muscles seemed necrotic so we debrided the dead tissue.
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Next we di the same on the right. The musce was more pale and white and did not contract. We did not have much swelling of the muscle. We debrided deep any dead muscle.
We irrigated then placed a woundvac over the two wounds,
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We will re look at the muscle in 3-5 days with wound vac change and possible closure.

Postop dx:L4-L5 spinal stenosis with left paracentral herniated disk.
Procedure in summary:
Placed prone on Jackson OSI table, Multiplanar fluoroscopy was brought into view where the L4-L5 level was identified. through a midline incision, dissection was carried down through skin and subcutaneous tissue down to the level of the lumbar fascia. This was incised and the L4-L5 segment was identified.performed a central laminectomy at the L4 level followed by hemilaminectomy at the L5 level using a combination of Leksell rongeur as well as Kerrison punches. A severe spinal stenosis noted at L4-L5, moderate paracentral herniated disk was also noted at the left L4-L5 segment. This was removed in its entirety and then attention was directed to the L4-L5 level. The disk space was flushed without any recurrent fragments. Intraoperative microscope was used to visualize the fine structures in the field and performed a tedious dissection of the stenosis in the 4-5 segment. The wound was then copiously irrigated and closed in layers. Not sure if 63030 is the only code I can use?
thank you

PROCEDURE:
1. Removal of implants bilateral T4
2. Exploration of fusion L5-S1
3. Reinsertion of spinal fixation device L4
4. Left sided pelvic fixation
5. Posterior instrumentation C2-T6 and T10 to S1, except L4
6. Posterior spinal fusion C2-T6 and T10-L5
7. Posterior column osteotomy T2-3, 3-4, L2-3
8. Transforaminal lumbar interbody fusion L2-3
9. Placement of interbody device L2-3
10. Left L3 transpedicular decompression
11. Myocutaneous flap coverage cervicothoracic spine
12. Placement and removal of mayfield tongs
13. Open Reduction Internal Fixation T4

A posterior midline skin incision was made through skin and subcutaneous tissue, and a posterior midline dissection in a subperiosteal fashion was performed. 2 separate incision were made from C2-T6 and then from T10-ileum.
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Next, at L3, the implants were removed, palpated and checked for any significant breaches, and left uninstrumented. The rods were cut bilaterally at this level. The right sided rod felt like it was about to break anyway.
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Posterior column osteotomies were then performed in the following manner from L2-3 in a revision manner: The ligamentum flavum was identified at all levels and resected. Next the superior articulating process was resected. The inferior articulating process was resected earlier in the procedure. This allowed for a complete posterior release with a disconnection of all the posterior elements between the vertebral bodies involved. Bleeding was controlled with bipolar electrocautery and packing of the osteotomy site.
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Next a transpedicular decompression was performed at L3 for purposes of decompression. This is performed by isolating the pedicle bilaterally, and then using a drill, and rongeur, the pedicles were removed to ensure adequate lateral decompression across a severely stenotic segment.
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Next a left sided approach was taken to L2-3 into the foramen. The thecal sac was dissected and retracted medially. The disc space was identified. It was entered with a knife. Sequential shaving and disc removal then was performed. The endplates were then denuded of cartilaginous material. Sequential trialing was performed and a size 12 mm implant was selected. It was prepared on the back table with bone graft. Bone morphogenic protein was placed in the anterior disc space. The implant was then placed and back filled with bone graft. This was then checked in AP and lateral planes. This graft is placed on the left side and kept to the left of midline as this is where the asymmetric graft placement needed to be performed to allow his coronal deformity correction to occur.
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Next between T10-S1 pedicle screws were placed in the following manner. Starting point was identified, bur was used to get the appropriate starting point, follow using a gearshift probe, this is used to cannulate the pedicle into the vertebral body. Next the ball-tipped probe was used to identify any medial lateral superior inferior or anterior breaches. Once confirmed that the trajectory was through the pedicle into the vertebral body, the appropriately sized pedicle screw was placed without any further sequela. At the conclusion of placing the pedicle screws all the screws were tested with EMG trigger testing and found to be within a satisfactory range, and were also examined with intraoperative fluoroscopy in the AP and lateral planes.
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Next the left iliac bolt set screw was removed and the fixation removed. IT was then reinserted to get adequate fixation into the pelvis.
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The area of previous fusion was then explored. Between L5-S1 the fusion was found to be solid with no need for additional arthrodesis.
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Next, from T10-L5, all bony surfaces were decorticated, and bone graft laid. This included both autograft harvested from the same incision as well as allograft bone in addition to bone morphogenic protein–2. Next all setscrews were final tightened manufacture specifications. Wounds are copiously irrigated with saline, and a final timeout was taken confirming good motor and sensory evoked potentials, vancomycin powder having been placed deep, drain having been placed deep, bone graft laid, and final tightening performed.
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The wounds were then copiously irrigated irrigated with saline, and the wound thoroughly inspected. Next the wound was closed in meticulous fashion with deep Vicryl sutures followed by superficial closure in the subcutaneous layer as well as closing the skin in a separate layer. Prineo was used on the skin. We then turned our attention to the proximal spine.
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Next starting point was obtained with a 2 mm bur from C2-T6. Next using a drill, the lateral mass was drilled to the appropriate depth. All of the pilot holes were tapped, followed by placing the appropriate length lateral mass screw C2-C6. Next between T1-T6 pedicle screws were placed in the following manner. Starting point was identified, bur was used to get the appropriate starting point, follow using a gearshift probe, this is used to cannulate the pedicle into the vertebral body. Next the ball-tipped probe was used to identify any medial lateral superior inferior or anterior breaches. Once confirmed that the trajectory was through the pedicle into the vertebral body, the appropriately sized pedicle screw was placed without any further sequela. At the conclusion of placing the pedicle screws all the screws were tested with EMG trigger testing and found to be within a satisfactory range, and were also examined with intraoperative fluoroscopy in the AP and lateral planes.
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The facet joints were then decorticated from C2 – T6 with the use of a bur, along with decorticating the lamina. Bone graft was then laid for fusion purposes.
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Posterior column osteotomies were then performed in the following manner from T2-4: The ligamentum flavum was identified at all levels and resected. Next the superior articulating process was resected. The inferior articulating process was resected earlier in the procedure. This allowed for a complete posterior release with a disconnection of all the posterior elements between the vertebral bodies involved. Bleeding was controlled with bipolar electrocautery and packing of the osteotomy site.
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Next 2 rods were cut and contoured to the appropriate sagittal and coronal alignment. There were secured distally. Then in a cantilever fashion the rod was brought to the screws spine was reduced including the fracture at T4. This completed the open reduction and internal fixation of the fracture. The rods were then seated into the screws, and set screws placed. This helped reduce the remainder of the patient’s deformity. The setscrews were then final tightened manufacture specifications
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