ICD-10-PCS code for the case sutdy 1. Operative Report PREOPERATIVE DIAGNOSIS: Gunshot wound to thespine POSTOPERATIVE DIAGNOSIS:
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ICD-10-PCS code for the case sutdy
1. Operative Report PREOPERATIVE DIAGNOSIS: Gunshot wound to thespine
POSTOPERATIVE DIAGNOSIS: Gunshot wound to the spine
PROCEDURE PERFORMED: Thoracic T12 laminectomy with removal ofbullet fragments and repair of dural tear
HISTORY: This 45-year-old sustained a gunshot wound to thespine. The bullet was lodged directly within the canal and into thespinal cord. The patient was reported to be paraplegic. He wasintubated and sedated and not really able to be examined. Wediscussed with the family the treatment options, includingconservative management versus bullet removal. They elected toproceed with this procedure.
OPERATIVE PROCEDURE: The patient was brought into the operatingtheater. Following the induction of general anesthesia, the patientwas turned from the supine to the prone position on the radiolucentWilson frame. We used C-arm to localize the bullet. The patientactually had two bullets, one in the subcutaneous layer at about L2and one in the spinal cord at T12. With localizing this, we madeour skin incision directly over both of these. We incised downthrough the fascia and removed the more superficial one, and thenwe opened the thoracolumbar fascia, staying on the patient’s leftside, dissecting the muscle attachments off, exposing the spinousprocess and lamina of T12. We drilled through this, entering intothe epidural space. Once we cleaned off the bone and ligamentumflavum, we got to the cerebrospinal fluid. There was a very largerent in the dura. We were able to work through this rent and weidentified the bullet fragment; it was intact, and we removed it.It came out in, of course, piecemeal fashion. Once we exploredlooking for the bullet fragment, we could see some lacerated nerveroots as well. Obviously the patient sustained quite significantintradural injury. Following removal of this, we used several 4-0Nurolon stitches to suture up the large dural rent. We could seethere were some dural root sleeves torn as well. These were, ofcourse, unamenable to direct closure. Then we used fibrin glue toseal this off. We closed the thoracolumbar fascia with 0 Nurolon,the dermis with inverted interrupted 2-0 Vicryl, the skin withstaples. Following this procedure, all instrument, sponge, needle,and patty counts were correct.
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