Operative Dictations:

NEUROSURGERY

Chaim B. Colen, M.D., Ph.D.

COPYRIGHT © 2008

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 Operative Dictation:

Colen Publishing, LLC

PO Box 35635
Grosse Pointe Woods, MI 48236
Author and Editor: Chaim B. Colen, M.D., Ph.D.
Editorial Assistant: Roxanne E. Colen, PA-C

COPYRIGHT © 2008 by Colen Publishing, LLC. This book, including all parts
thereof, is legally protected by copyright. Any use, exploitation, or
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Printed in the United States of America

ISBN 10: 1-935345-03-6

ISBN 13: 978-1-935345-03-9

Note: Knowledge in medicine is constantly changing. The author has consulted

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 Operative Dictation:

CONTENTS

Table of Contents
CONTENTS.......................................................................................................iii
CONTRIBUTORS...............................................................................................vi
DEDICATION...................................................................................................vii
PREFACE.........................................................................................................viii
FORWARD.......................................................................................................ix
OPERATIVE INSTRUMENTS..............................................................................1
PERFORATOR DRILL BITS/ BURRS........................................................2
DURAL SEPARATORS.............................................................................2
HOOKS...................................................................................................3
HOOKS...................................................................................................3
DISSECTORS...........................................................................................4
KERRISSON RONGEUR..........................................................................4
SCISSORS...............................................................................................4
SCISSORS/ CLAMPS/ FORCEPS.............................................................5
ELEVATORS............................................................................................6
ELEVATORS............................................................................................6
ELEVATORS............................................................................................7
SUCTION TIPS........................................................................................7
FORCEPS................................................................................................8
BAYONET FORCEPS................................................................................8
BAYONET FORCEPS................................................................................9
MICRO SCISSORS...................................................................................9
MICRO SCISSORS.................................................................................10
BIPOLAR BAYONET FORCEPS..............................................................10
SPECULUMS.........................................................................................11
RETRACTORS.......................................................................................11
NERVE ROOT RETRACTORS..................................................................12
CRANIAL PROCEDURES...................................................................................14
CRANIAL DICTATIONS GUIDE.......................................................................................... 15
BURR HOLE DRAINAGE FOR........................................................................................... 17
CHRONIC SUBDURAL HEMATOMA (SDH) EVACUATION..............................................17
CRANIOTOMY FOR........................................................................................................... 20
ACUTE SUBDURAL HEMATOMA (SDH) EVACUATION.................................................20
CRANIOTOMY FOR........................................................................................................... 23
ACUTE EPIDURAL HEMATOMA (EDH) EVACUATION..................................................23
DECOMPRESSIVE CRANIECTOMY FOR...........................................................................26
INTRACRANIAL HEMORRHAGE/STROKE/ TRAUMATIC BRAIN INJURY.......................26
CRANIOPLASTY................................................................................................................... 30
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OMMAYA RESERVOIR PLACEMENT................................................................................34

TRANSSPHENOIDAL HYPOPHYSECTOMY.........................................................................38
CRANIOTOMY FOR MCA ANEURYSM CLIPPING.......................................................... 42
STEREOTACTIC FRAMELESS............................................................................................. 48
BURR HOLE CRANIOTOMY FOR BIOPSY........................................................................48
STEREOTACTIC CRANIOTOMY FOR SUPRATENTORIAL BIOPSY...................................52
CRANIOTOMY FOR........................................................................................................... 56
STEREOTACTIC TUMOR RESECTION WITH MAPPING AND MONITORING.................56
CRANIOTOMY WITH ORBITAL OSTEOTOMY..................................................................62
PTERIONAL OSTEOPLASTIC CRANIOTOMY.....................................................................68
TRANSCORTICAL INTRAVENTRICULAR TUMOR RESECTION.........................................74
CHIARI DECOMPRESSION................................................................................................. 79
STEREOTACTIC SUBOCCIPITAL CRANIECTOMY.............................................................. 83
RETROSIGMOID CRANIOTOMY TRANSCONDYLAR APPROACH....................................88
GAMMA‐KNIFE STEREOTACTIC RADIOSURGERY...........................................................93
FUNCTIONAL, EPILEPSY AND PAIN................................................................96
EPILEPSY SURGERY STAGE I: LONG TERM MONITORING ELECTRODES
PLACEMENT....................................................................................................................... 97
EPILEPSY SURGERY STAGE II: PRE MOTOR CORTEX LESION RESECTION..............101
STAGE II EPILEPSY SURGERY: TEMPORAL LOBE LESION RESECTION......................107
MICROVASCULAR DECOMPRESSION.............................................................................114
DEEP BRAIN STIMULATOR (DBS) LEAD PLACEMENT...............................................118
DEEP BRAIN STIMULATOR (DBS) GENERATOR PLACEMENT..................................126
RHIZOTOMY: MEDIAL FACET BRANCH.......................................................................129
CARPAL TUNNEL RELEASE............................................................................................ 132
ULNAR NERVE DECOMPRESSION.................................................................................. 135
PERONEAL NERVE DECOMPRESSION...........................................................................138
SPINAL CORD STIMULATOR PLACEMENT....................................................................142
VAGAL NERVE STIMULATOR IMPLANTATION............................................................. 146
SHUNTING PROCEDURES.............................................................................150
VENTRICULO‐PERITONEAL SHUNT PLACEMENT........................................................151
LUMBAR PERITONEAL SHUNT PLACEMENT................................................................155
THIRD VENTRICULOSTOMY............................................................................................ 158
SPINAL PROCEDURES...................................................................................163
SPINAL DICTATIONS GUIDE......................................................................................... 164
ANTERIOR CERVICAL DISCECTOMY AND FUSION......................................................165
CERVICAL CORPECTOMY................................................................................................ 174
CERVICAL LAMINECTOMY WITH LATERAL MASS ARTHRODESIS.............................179
CERVICAL LAMINOPLASTY............................................................................................. 184
LAMINECTOMY FOR INTRAMEDULLARY SPINAL CORD TUMOR...............................188
LAMINECTOMY FOR EXCISION OF INTRADURAL EXTRAMEDULLARY SPINAL CORD
TUMOR............................................................................................................................ 193
LUMBAR HEMILAMINECTOMY MICRODISCECTOMY...................................................198
LUMBAR LAMINECTOMY‐ BILATERAL.......................................................................... 202
MINIMALLY INVASIVE: LUMBAR LAMINECTOMY DISCECTOMY...............................206

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PERCUTANEOUS DISCECTOMY...................................................................................... 210

POSTERIOR LUMBAR INTERBODY FUSION................................................................. 213
REDO INSTRUMENTATION REMOVAL.......................................................................... 218
THORACIC CORPECTOMY: LATERAL EXTRACAVITARY APPROACH...........................224
THORACIC CORPECTOMY: TRANSTHORACIC APPROACH..........................................231
X‐STOP........................................................................................................................... 236
VASCULAR/ENDOVASCULAR.......................................................................239
PROCEDURES...............................................................................................239
CAROTID ENDARTERECTOMY.........................................................................................240
CEREBRAL ANGIOGRAPHY............................................................................................. 244
CEREBRAL ANGIOGRAM WITH ANEURYSM COILING................................................248
CEREBRAL ANGIOGRAM WITH STENT‐ASSISTED ANEURYSM COILING...................254
CEREBRAL ANGIOGRAM WITH ARTERIO‐VENOUS MALFORMATION (AVM)
EMBOLIZATION............................................................................................................... 260
ANGIOGRAM WITH CAROTID BALLOON ANGIOPLASTY AND STENT PLACEMENT
............................................................................................................. 266
MINOR PROCEDURES..................................................................................272
ARTERIAL LINE PLACEMENT......................................................................................... 273
LUMBAR SPINAL PUNCTURE........................................................................................ 275
LUMBAR DRAIN PLACEMENT....................................................................................... 278
VENTRICULOSTOMY PLACEMENT................................................................................. 281
VERTEBROPLASTY/KYPHOPLASTY.................................................................................... 284
APPENDIX.....................................................................................................288
ABBREVIATIONS...........................................................................................289

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CONTRIBUTORS
FACULTY REVIEWERS
Alan Scarrow, M.D., J.D.
St. John's Clinic - Neurosurgery
1965 S. Fremont Ste. 130
Springfield, MO 65804

Gregory Przybylski, M.D.

Director of Neurosurgery
New Jersey Neuroscience Institute
JFK Medical Center, Edison, New Jersey

RESIDENTS
Raul Olivera, M.D.
Division of Neurosurgery
Department of Surgery
Saint Louis University School of Medicine
St. Louis, MO 63110

Clemens M. Schirmer, M.D.

Department of Neurosurgery
Tufts New England Medical Center
Boston, MA

MEDICAL STUDENTS
Alexandria Conley
Wayne State University
Detroit, MI

Christopher E. Lai
Wayne State University
Detroit, MI

Brett Justin Mollard

Wayne State University
Detroit, MI

Adam Robin
Wayne State University
Detroit, MI

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 Operative Dictation:

DEDICATION

I dedicate this effort to my ever-supportive wife Roxanne, daughter Emily and

son Joshua whose love, patience and encouragement allowed me to achieve
the completion of this book.

My Motto: If you love yourself, you will love your patient and your patient
will love you. Live, Love and leave a Legacy.
Chaim Benjoseph Colen M.D., Ph.D. 09/03/02

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 Operative Dictation:

PREFACE
Concern for man and his fate must always form the chief
interest of all technical endeavors… Never forget this in the
midst of your diagrams and equations.
Albert Einstein
Operative dictations are an essential part of the neurosurgical
career. Excellent operative dictations can be likened to "Fidelio" the
beautiful Beethoven masterpiece. Each word must flow on a
musical note; translating 3‐dimensional neuroanatomic melodies
into a verbalized anatomic clinico‐surgical masterpiece. On the
other hand, a poor operative dictation can be perceived as the lack
of clinico‐scientific knowledge or poor comprehension of the
operation that was just performed.

Operative Dictations: Neurosurgery is meant to provide the basic

musical notes needed to come closer to achieving a verbalized
operative "Beethoven masterpiece". It provides illustrations of
basic operative instruments and skeleton operative dictations with
their respective CPT codes; to assist the novice surgeon in
becoming a verbally skilled surgeon. Practice makes perfect and by
rehearsing your operation in a well structured, systematic and
cohesive fashion, you will improve your operative efficiency and
medico‐legal sustaining jargon; a prerogative in our day.

In no way is this book comprehensive enough to cover all operative

dictations performed in neurosurgery; rather it is meant to be a
basic guide to allow the novice surgeon the scaffolding needed to
dictate a basic straight forward case. The most common cases are
described in a consistent format, with bolded statements meant to
reinforce the most important segments from the medico‐legal
standpoint. There are many times during our operative careers that
we deviate from the norm; this uniqueness should be dictated on a
per‐case‐basis. May this book benefit all residents and junior staff,
with the ultimate goal of improving our verbalized legacy of
Neurosurgery.
Chaim B. Colen
2008

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 Operative Dictation:

FORWARD
Most of us went into neurosurgery because we had a passion for
clinical tasks of our profession – listening to patients, thinking
about how to help them, performing the surgery, and finding out if
our efforts have helped them. I am confident very few of us have a
similar passion for the dictation, documentation, and paperwork
that necessarily accompany those more pleasant clinical tasks.
Nonetheless accurately recording what we do in our clinical and
surgical work is not just a good medico‐legal practice, it’s simply
good medicine.

In this book, Dr. Colen has made the task of documenting our
surgical work much easier. What follows are detailed operative
notes and CPT coding for the typical surgical work we do involving
spine, tumor, vascular, functional, and stereotactic procedures.
This will allow readers to take these templates, modify them to
their own unique variations for an individual procedure, and
incorporate them into the patient’s medical record. This should be
particularly helpful to those who are new to the responsibilities of
medical and surgical documentation.

In publishing this work, Dr. Colen is helping us as neurosurgeons

spend more time doing the things we love, and less time recording
how we did them. It is an admirable ambition.

Alan M. Scarrow, M.D., J.D.

Chairman, Section of Neurosurgery
St. John’s Clinic
Springfield, Missouri

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OPERATIVE INSTRUMENTS

L'OPÉRATION DU TRÉPAN
Trepanation is one of the earliest cranial operations performed by man. It was c

Encyclopédie Ou Dictionnaire Raisonné Des Sciences, Des Arts Et Des Métiers, 1772

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HOOKS

1 2 3 4 5 6 7

1. Sachs dural hook HOOKS

2. Cushing dural hook
3. Frazier dural hook
4. Lahey clinic dural hook
5. Strully dural twist hook
6. Dandy nerve hook
7. Adson dural hook

1 2 3 4 5 6 7
3
1. Hoen nerve hook, straight
2. Hoen nerve hook, angled
3. Smithwick hook & dissector
4. Murphy ball hook
5. Cushing gasserian ganglion hook, blunt
6. Smithwick button hook, blunt
7. Davis nerve separator/spatula
Operative Dictation: Neurosurgery

DISSECTORS

1 2 3 4 5 6 7 8

1. Penfield dissector, #1
2. Penfield KERRISSON
dissector, #2 RONGEUR
3. Penfield dissector, #3
4. Penfield dissector, #4
5. Penfield dissector, #5
6. Double dissector, sharp/blunt
7. Woodson elevator/spatula double end
8. Woodson separator/packer, double end

4 1. Kerrisson rongeurSCISSO
 Operative Dictation:

PTERIONAL OSTEOPLASTIC CRANIOTOMY

DATE OF SURGERY:
SURGEON: Dr. X
ASSISTANT: Dr. Y
PREOPERATIVE DIAGNOSIS: (Right/Left) clinoidal mass.
POSTOPERATIVE DIAGNOSIS: (Right/Left) clinoidal
(meningioma).

PROCEDURES PERFORMED:
1. Stereotactic (Right/Left) pterional osteoplastic
craniotomy with resection of clinoidal/sphenoid wing
mass.
2. Intraoperative use of microscope for microdissection.
3. Intraoperative electrophysiological monitoring with SSEPs
and motor evoked potentials.

CPT Coding
61592 Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and ca
61795 Stereotactic computer‐assisted volumetric (navigational) procedure, intracranial
69990 Microsurgical techniques, requiring use of operating microscope (List separately

ANESTHESIA: GETA.
ESTIMATED BLOOD LOSS: (XX) cc.
FINDINGS: Frozen section was consistent with .
DRAINS: (JP/Blake) drain.
COMPLICATIONS: None.
DISPOSITION: Stable to the PACU.

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INDICATIONS FOR THE PROCEDURE

HISTORY: (Mr./Ms.) (Pt. Name) is a (Pt. Age) year old
(Male/Female) who presents with signs and symptoms
consistent with a clinoidal/sphenoid wing mass (double
vision, blurry vision, cranial nerve palsy). The goal of the
operation was optic and cranial nerve decompression.
DIAGNOSTIC STUDIES: MRI brain showed .
SURGICAL RISKS: The patient (family/N.O.K./P.O.A.) was
well apprised of all objectives, benefits, risks and potential
complications of the procedure, including but not limited
to: worsening of current status, the possible need for
further procedures, the risk of infection, headaches, CSF
leak, seizures, hemorrhage, stroke, loss of language
function, paralysis, coma and even death. Informed consent
was obtained and secured in the chart after the patient
(family/N.O.K./P.O.A.) voiced understanding of these risks
and decided to proceed with the operation.

DESCRIPTION OF THE PROCEDURE:

The patient was transferred to the operating room. (He/She)
was given preoperative prophylactic IV antibiotics.
ANESTHESIA: The patient was sedated and intubated
without difficulty by the anesthesia service. Eyes were taped
shut after ointment was applied to prevent corneal abrasion.
A Bair Hugger was placed over the exposed lower body to
maintain control of core body temperature. A Foley catheter
was inserted.
POSITIONING: A Mayfield head clamp was applied. The
patient was positioned supine with the head turned
approximately (XX) degrees to the (Right/Left) with very mild
extension. All pressure points were carefully padded. The
hair was clipped over the area where (He/She) was to
undergo the incision. Pre‐prepping was done with
(chlorhexidine solution, alcohol). The electrophysiology
monitoring team inserted needles in their proper locations
and baseline SSEPs and motor evoked potentials were

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 Operative Dictation:

obtained. Stereotactic CT/MRI was done on the morning of

the surgery and the images were transferred to the
neuronavigational system. Next, three‐dimensional images
were reconstructed. The patient underwent co‐registration
of the preoperative stereotactic CT/MRI with (His/Her)
surface landmarks. Accuracy was within 2mm.
Vital structure landmarks including the (motor area/speech
area/superior sagittal sinus) were identified and mapped
out. The planned craniotomy was outlined.
OPERATIVE TECHNIQUE: The patient was prepped and
draped in standard sterile fashion.
IF FAT GRAFT WILL BE USED: The (Right/Left) lower abdomen
was prepped and draped as well in standard sterile fashion.
Local anesthesic was infiltrated along the line of planned and
marked skin incision. A (Right/Left) fronto‐temporal (C‐
shaped, question mark) incision was opened sharply with a #
(XX) scalpel blade to the level of the periosteum.
Subcutaneous dissection was performed sharply with
Metzenbaum scissors, preserving the superficial temporal
artery and its branches. Interfascial dissection was
completed along the superficial temporalis muscle fascia to
preserve the frontalis branch of the facial nerve. The skin
flap was reflected anteriorly leaving the temporalis muscle in
place.
Osteoplastic craniotomy was performed by leaving the
temporalis muscle and periosteum attached to the temporal
bone.
The frontal bone periosteum was elevated parallel to the
orbital ridge approximately (X) cm superior to the ridge and
followed along the orbital zygomatic arch. Care was taken to
identify and preserve the supraorbital nerve at the
supraorbital (notch/foramen). Elevation of the periosteum
was continued along the zygomatic arch from medial to
lateral.
A small portion of the temporalis muscle was dissected from
the supero‐anterior bone and the infero‐posterior bone. The

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 Operative Dictation:

high speed (electric/ pneumatic) drill was utilized to make

(XX) craniotomy burr holes; one at the pterion (“MacCarty
keyhole” ‐keyhole burr hole) the second at the squamous
temporal and the third at the superior medial frontal bone
(posterior temporal). The dura was dissected free
underneath all burr holes. With the B1 bit and footplate, the
burr holes were interconnected and a craniotomy
completed. The osteoplastic bone flap was freed from the
dura with #3 Penfields and was reflected anterolaterally still
attached to its temporalis pedicle and held in place with fish‐
hooks. The dura was visualized (intact/with durotomy).
Hemostasis was achieved utilizing a combination of bipolar
electrocautery and absorbable gelatin compressed sponge
(Gelfoam). The wound was irrigated until clear.
The dura was opened in a (C‐shape, S‐shape) fashion.
(Mannitol 25gm IV was given by the anesthesia team).
Several (X)‐0 non‐absorbable braided polyamide suture
(Nurolon) tacking sutures were used to elevate the dura
anteriorly.
The Buddy halo was attached to the Mayfield headholder. At
this point the operative microscope was draped with sterile
drapes and brought into the operative field. With
microdissection technique the Sylvian fissure was opened
and the dural based tumor came into view. Minimal brain
retraction was required. Hemostasis was achieved utilizing
bipolar electrocautery and absorbable gelatin compressed
sponge (Gelfoam). [Absorbable gelatin compressed sponge
(Gelfoam) was neatly tucked circumferentially around the
craniotomy just underneath the dura to prevent blood from
reaching other areas of the brain.]
The (Right/Left) optic nerve was identified and the
opticocarotid cistern opened to allow CSF egress and brain
decompression.
IDENTIFICATION OF STRUCTURES: The internal carotid
artery, optic nerve and third cranial nerve were identified.

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 Operative Dictation:

FINDINGS: (intra/extracavernous tumor compression of

cranial nerves, arterial constrictions by tumor). The lesion
was noted to be (color, swelling, consistency, [well‐defined,
ill‐defined] planes, dural attachments).
WHAT WAS DONE: Microdissection with tumor resection,
further drilling of the anterior clinoid, unroofing the third
cranial nerve, decompression of the superior orbital fissure
contents, mobilizing the dura propria from the lateral wall of
the cavernous sinus. Tumor extirpation was performed
through the opticocarotid, carotid–oculomotor, and
prechiasmatic spaces. Attention was paid to avoid violating
the perforating arteries situated in the opticocarotid
triangle.
A nerve hook was used to carefully dissect tumor near the
optic foramen. [To avoid risk of devascularizing the optic
nerve, further attempts of removing this tiny bit of tumor
were abandoned]. Careful bipolar electrocautery was used
to achieve hemostasis on all dural edges and the dura was
stripped from the clinoid process and the medial most part
of the sphenoid wing. The wound was irrigated until clear.
Verification of volumetric resection was performed with the
neuronavigational probe. The tumor was sent to pathology.
Having accomplished the goal of decompression of the optic
nerve, superior orbital fissure and cranial nerves, we
proceeded with harvesting of a fat graft from the abdomen.
IF FAT WILL BE USED: An incision was made in the
anterior (Right/Left) lower quandrant part of the
abdomen. Fat was obtained and hemostasis promptly
achieved. The fascia was approximated with (X)‐0
polyglactin synthetic absorbable suture (Vicryl). The skin
was then closed with (nylon suture, skin‐glue, steri‐
strips, surgical staples). A sterile dressing was placed
over the closed wound.
The fat graft was placed between the inferior aspect of the
optic nerve, the carotid artery and the superior orbital
fissure. The optic nerve was gently separated in this fashion

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 Operative Dictation:

from the parasellar region in anticipation of potential

stereotactic radiosurgery at a later date. The field was
irrigated clear.
The dura was closed in a water‐tight fashion with
interrupted (X)‐0 non‐absorbable braided polyamide suture
(Nurolon). The dural defect created at the orbital apex from
removal of the dura from the anterior clinoid process was
covered with fat graft to prevent CSF leak. The bone flap was
replaced and affixed with miniplates and screws.
(Cranioplasty: The cranial defect was reconstructed using a
synthetic cranioplasty implant.) The wound was irrigated
with antibiotic solution. The temporalis muscle was
reapproximated with (X)‐0 polyglactin synthetic absorbable
suture (Vicryl) and secured onto the bone flap. The galea
was reapproximated utilizing inverted interrupted (X)‐0
polyglactin synthetic absorbable suture (Vicryl). The skin was
then closed with (nylon suture, skin‐glue, steri‐strips,
surgical staples). A sterile head dressing was placed over the
closed wound.

All needle counts, sponge counts and instrument counts

were correct at the end of the case times two. The patient
tolerated the procedure well and was transferred to the
recovery room in stable condition. Dr. X was present during
the critical portions of this case.

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 Operative Dictation:

FUNCTIONAL, EPILEPSY AND

PAIN
1. Epilepsy Surgery Stage I: Long Term Monitoring
Electrodes Placement.
2. Epilepsy Surgery Stage II: Premotor Cortex Lesion
Resection.
3. Epilepsy Surgery Stage II: Temporal Lobe Lesion
Resection.
4. Microvascular Decompression.
5. Deep Brain Stimulator Lead Placement.
6. Deep Brain Stimulator Generator Placement.
7. Rhizotomy: Medial Facet Branch.
8. Carpal Tunnel Release.
9. Ulnar Nerve Decompression.
10. Peroneal Nerve Lysis.
11. Spinal Cord Stimulator Placement.
12. Vagal Nerve Stimulator Implantation.

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 Operative Dictation:

SHUNTING PROCEDURES
1. Ventricular Peritoneal Shunt Placement
2. Lumbar Peritoneal Shunt Placement
3. Endoscopic Third Ventriculostomy

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 Operative Dictation:

SPINAL PROCEDURES
Spinal Dictations Guide
1. Anterior Cervical Discectomy and Fusion (ACDF)
2. Anterior Lumbar Interbody Fusion (ALIF)
3. Cervical Corpectomy
4. Cervical Laminectomy with Lateral Mass Arthrodesis
5. Cervical Laminoplasty
6. Extreme Lateral Interbody Fusion (XLIF)
7. Laminectomy for Intramedullary Spinal Tumor
8. Laminectomy for Excision of Intradural
Extramedullary Spinal Tumor
9. Lumbar Hemilaminectomy and Microdiscectomy
10. Lumbar Laminectomy‐ Bilateral
11. MIS Laminectomy
12. Percutaneous Discectomy
13. Posterolateral Interbody Fusion (PLIF)
14. Redo Instrumentation Removal
15. Thoracic Corpectomy Lateral Extracavitary
Approach
16. Thoracic Corpectomy Transthoracic Approach
17. X‐Stop

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 Operative Dictation:

SPINAL DICTATIONS GUIDE

In Neurosurgery there are a lot of spinal procedures with a
lot of different codes. These codes are constantly changing.
When using this section remember to keep in mind that you
should consult an official CPT book for accurate coding for
purposes of reimbursement.

Some procedures are performed with electrophysiological

monitoring (see Cervical Laminoplasty for example). The CPT
coding is provided here for your quick review.

In CPT
cases where fluoroscopic guidance is used during the
Coding
spinal proceduremotor
95929 Central consider using
evoked the following
potential CPT codes:
study (transcranial motor
stimulation); lower limbs
95928 Central motor evoked potential study (transcranial motor
In CPT Coding
cases whereupper
stimulation); bone marrow aspirate is used during the
limbs
20986
spinal Computer‐assisted
procedure consider surgical
using thenavigational
following procedure
CPT code: for
95926 Short‐latency somatosensory
musculoskeletal procedures; with image evoked potential
guidance study,
based on
stimulation of any/all
intraoperatively peripheral
obtained imagesnerves or skin sites,
(eg, fluoroscopy, recording (List
ultrasound)
CPT
from Coding
the central nervous system; in lower limbs
separately inmarrow;
additionaspiration
to code foronly
primary procedure)
1 38220
95925 Bone
Short‐latency somatosensory evoked potential study,
77002 Fluoroscopic guidance for needle placement (eg, biopsy,
stimulation of any/alllocalization
aspiration, injection, peripheral nerves
device)or skin sites, recording
from the central nervous system; in upper limbs
 Operative Dictation:

ANTERIOR CERVICAL DISCECTOMY AND

FUSION
DATE OF SURGERY:
SURGEON: Dr. X
ASSISTANT: Dr. Y
PREOPERATIVE DIAGNOSIS: C(LEVEL)‐C(LEVEL) radiculopathy
and herniated cervical disc.
POSTOPERATIVE DIAGNOSIS: C(LEVEL)‐C(LEVEL)
radiculopathy and herniated cervical disc.

PROCEDURE PERFORMED:
1. C(LEVEL)‐C(LEVEL) anterior cervical discectomy with
decompression of spinal cord and osteophytectomy.
2. C(LEVEL)‐C(LEVEL) anterior interbody arthrodesis.
3. C(LEVEL)‐C(LEVEL) insertion of interbody allograft.
4. Microsurgical techniques, requiring use of operating
microscope for discectomy and osteophytectomy.
5. C(LEVEL)‐C(LEVEL) anterior plate and screws.
6. Fluoroscopic guidance for localization and
instrumentation.
CPT Coding
20931 Allograft for spine surgery only; structural (List separately in addition to
22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in a
22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage
22554 Arthrodesis, anterior interbody technique, including minimal discectomy
63075 Discectomy, anterior, with decompression of spinal cord and/or nerve r

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 Operative Dictation:

CPT Coding (Cont.)

69990 Microsurgical techniques, requiring use of operating microscope (List separate
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection,

ANESTHESIA: GETA.
ESTIMATED BLOOD LOSS: (XX) cc.
FINDINGS:
DRAINS: (JP/Blake) drain.
COMPLICATIONS: None.
DISPOSITION: Stable to the PACU

INDICATIONS FOR THE PROCEDURE Mr./Ms. (Pt. Name) is a

(Pt. Age) year old (Male/Female) who presents with signs,
symptoms and radiographic evidence of (Right/Left) neck
pain radiating into (His/Her) (Right/Left) arm in a C(LEVEL)
dermatomal pattern.
DIAGNOSTIC STUDY: MRI cervical spine showed .
(He/She) had failed conservative treatment (physical
therapy, pain medication, epidural steroids) and (His/Her)
symptoms continued to progress. Given the progression of
the symptoms, it was decided to proceed with the
decompression of the herniated disc and osteophyte
complex at C(LEVEL).
SURGICAL RISKS: The patient (family/ N.O.K./ P.O.A.) were
apprised of all objectives, benefits, risks and potential
complications of the procedure, including but not limited
to: worsening of current status, the possible need for
further procedures, the risk of infection, headaches, CSF
leak, possible spinal cord injury resulting in paralysis,
infection, neck hematoma and hoarseness of voice, injury
to major vessels causing hemorrhage, stroke, loss of
language function, coma and even death. Informed consent
was obtained and secured in the chart after the patient

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 Operative Dictation:

(family/ N.O.K./ P.O.A.) voiced understanding of these risks

and decided to proceed with the operation.

DESCRIPTION OF THE PROCEDURE

The patient was transferred to the operating room. (He/She)
was given preoperative prophylactic IV antibiotics.
ANESTHESIA: The patient was sedated and intubated
without difficulty by the anesthesia service. Eyes were taped
shut after ointment was applied to prevent corneal abrasion.
A Bair Hugger was placed over the lower body to maintain
control of core body temperature. A Foley catheter was
inserted.
POSITIONING: The patient was placed in the supine position
with a gel roll underneath (His/Her) head. All pressure
points were carefully padded.
OPERATIVE TECHNIQUE: The skin was prepped and draped in
the standard surgical fashion and the area marked with a
marking pen utilizing standard landmarks such as midline
and cricoid cartilage.
A transverse neck incision was performed opposite the
C(LEVEL)‐C(LEVEL) level using a # (XX) scalpel blade after
infiltration with (XX) % Marcaine with epinephrine. The
incision was deepened through platysma muscle and the
edges undermined using sharp dissection. Hemostasis was
obtained utilizing Bovie electrocautery as well as the bipolar
forceps. Further blunt and sharp dissection was carried
down in the plane medial to the omohyoid muscle. Blunt
dissection was performed medial to the carotid sheath down
to the anterior longitudinal ligament in front of the spine.
The C‐arm fluoroscopy unit was draped with sterile drapes
and brought into the operative field. The level of C(LEVEL)‐
C(LEVEL) was confirmed by placing a marker needle and
fluoroscopic x‐ray. The longus coli muscle was undermined
with monopolar electrocautery on either side until the
uncovertebral joints were exposed. Self‐retaining retractors

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 Operative Dictation:

VASCULAR/ENDOVASCULAR
PROCEDURES
1. Carotid Endarterectomy
2. Cerebral Angiography
3. Cerebral Angiogram with Aneurysm Coiling
4. Cerebral Angiogram with Stent‐assisted Aneurysm
Coiling
5. Cerebral Angiogram with AVM embolization
6. Angiogram with Carotid Balloon Angioplasty and
Stent
Placement

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 Operative Dictation:

CEREBRAL ANGIOGRAPHY
DATE OF PROCEDURE:
RADIOLOGIST/SURGEON: Dr. X
ASSISTANT: Dr. Y
PREOPERATIVE DIAGNOSIS: (Subarachnoid hemorrhage,
carotid stenosis).
POSTOPERATIVE DIAGNOSIS: (Subarachnoid hemorrhage,
carotid stenosis).

PROCEDURES PERFORMED:
1. Bilateral (vessel) angiogram‐cervical.
2. Bilateral (vessel) angiogram‐cerebral.
3. Rotational 3D (Right/Left) (vessel) angiogram.
4. Bilateral vertebral artery angiogram‐bilateral.
5. (Right/Left) common femoral artery angiogram.
6. Deployment of a (X)‐French Angio‐Seal within the right
femoral artery.

CPT Coding
75676 Angiography, carotid, cervical, unilateral, radiological supervision and interpretati
75671 Angiography, carotid, cerebral, bilateral, radiological supervision and interpretati
75685 Angiography, vertebral, cervical, and /or intracranial, radiological supervision and
75774 Angiography, selective, each additional vessel studied after basic examination, ra

ANESTHESIA: IV sedation with local anesthesia.

ESTIMATED BLOOD LOSS: (XX) cc.
FLUORO TIME: (XX) minutes and (XX) seconds.
CONTRAST: Intravenous contrast agent (XX) cc.
FINDINGS:

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 Operative Dictation:

1. Report AVM, aneurysm remnants if clipped, vessel

stenosis.
2. Report arterial, capillary, and venous opacification on all
angiographic runs.
COMPLICATIONS: None.
DISPOSITION: Stable to the PACU.

INDICATIONS FOR THE PROCEDURE

HISTORY: (Mr./Ms.) (Pt. Name) is a (Pt. Age) year old
(Male/Female) with signs, symptoms and radiographic
evidence of (Right/Left) [(Acom, Pcom, MCA, Basilar tip)
aneurysm] or [carotid artery stenosis].
DIAGNOSTIC STUDY: MRI/CT/CTA/MRA brain showed .
PROCEDURE RISKS: The patient (family/N.O.K./P.O.A.) was
well apprised of all objectives, benefits, risks and potential
complications of the procedure, including but not limited
to: worsening of current status, the possible need for
further procedures, the risk of infection, seizures,
hemorrhage, stroke, loss of language function, paralysis,
coma and even death. Informed consent was obtained and
secured in the chart after the patient (family/N.O.K./P.O.A.)
voiced understanding of these risks and decided to proceed
with the procedure.

DESCRIPTION OF THE PROCEDURE

The patient was transferred to the angiography suite.
(He/She) was given preoperative prophylactic IV antibiotics.
ANESTHESIA: The patient was given IV sedation by the
anesthesia team.
POSITIONING: The patient was placed in the supine position
on the angio table. The groins were prepped and draped
bilaterally in the usual sterile fashion.
TECHNIQUE: The pulse of the common femoral artery was
felt on the (Right/Left) groin and the overlying skin was
infiltrated with (XX) % lidocaine. A stiff micropuncture set
was utilized to gain access to the vessel. Pulsatile bright red

2
 Operative Dictation:

MINOR PROCEDURES
1. Arterial Line Placement
2. Lumbar Spinal Puncture
3. Lumbar Drain Placement
4. Ventriculostomy Placement
5. Vertebroplasty/ Kyphoplasty

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Operative Dictation: Neurosurgery

APPENDIX
Hydrogel dural sealant (DuraSeal)
Oxidized cellulose absorbable hemostat (Surgicel)
Synthetic cotton absorbant sponge (Cottonoid)
Polyglactin synthetic absorbable suture (Vicryl) Non‐
absorbable braided polyamide suture (Nurolon)
Absorbable gelatin compressed sponge (Gelfoam)
Microfibrillar collagen hemostat (Avitene)
Poliglecaprone 25 (Monocryl)
Adhesive skin closure (Steri‐Strips)
Synthetic non‐absorbable polypropylene suture (Prolene)

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Operative Dictation: Neurosurgery

ABBREVIATIONS
ACA = Anterior cerebral artery
Acom = Anterior communicating artery
AP = Anterior‐Posterior
BMP = Bone morphogenic protein
C = Cervical
CSF = Cerebrospinal fluid
CT = Computed tomography
CT = Computed tomographic
angiography CUSA = cavitron ultrasonic
aspirator GETA = General endotracheal
anesthesia L = Lumbar
MEP = Motor‐evoked potentials
MCA = Middle cerebral artery
MRA = Magnetic resonance angiography
MRI = Magnetic resonance imaging
NOK = Next of kin
PCA = Posterior cerebral artery
Pcom = Posterior communicating artery
POA = Power of attorney
S = Sacral
SSEP = Somotosensory‐evoked potentials
T = Thoracic

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