Location: Inpatient Hospital
OPERATIVE REPORT
PRE/POSTOPERATIVE DIAGNOSIS: Herniated disc L4-5 on the left.
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc at L4-5 on the left.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: Under general anesthesia the patient was placed in the prone position. The back was prepped and draped in the usual manner. Incision was made in the skin and extended through subcutaneous tissue. The lumbodorsal 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 laminectomy/foraminotomy and saw the problem. There was sequestered disc on the body of L4-L5. I entered the disc space and removed much degenerating material both medially and laterally. Having cleaned out the disc space, I was satisfied the root was decompressed. We passed a hockey stick down the foramen and laterally there were no free fragments. We then irrigated 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 the recovery room in stable condition.
CPT Code: ____________________

Question

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The Answer of Location: Inpatient Hospital
OPERATIVE REPORT
PRE/POSTOPERATIVE DIAGNOSIS: Herniated disc L4-5 on the left.
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc at L4-5 on the left.
ANESTHESIA: General.
DESCRIPTION OF PROCEDURE: Under general anesthesia the patient was placed in the prone position. The back was prepped and draped in the usual manner. Incision was made in the skin and extended through subcutaneous tissue. The lumbodorsal 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 laminectomy/foraminotomy and saw the problem. There was sequestered disc on the body of L4-L5. I entered the disc space and removed much degenerating material both medially and laterally. Having cleaned out the disc space, I was satisfied the root was decompressed. We passed a hockey stick down the foramen and laterally there were no free fragments. We then irrigated 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 the recovery room in stable condition.
CPT Code: ____________________

Location: Inpatient Hospital OPERATIVE REPORT