AHA Coding Clinic® for ICD-9 - 2007 Issue 1; Ask the Editor

Vertebral Burst Fracture

The patient is a 47-year-old man who fell from a ladder sustaining an L2 burst fracture ten months ago. At that time, because he was neurologically intact, he was managed conservatively. However, the low back pain and lower extremity weakness became progressively worse. Follow-up MRI of the spine showed severe lumbar spinal stenosis, kyphotic deformity, loss of vertebral body height and retropulsed bone fragments with approximately 20% canal compromise. Because of the severe lumbar spinal stenosis and kyphosis with progression of symptoms, surgical intervention was carried out. Retroperitoneal (anterior) exposure of the lumbar spine was first accomplished in order to get to the lumbar vertebral bodies. The patient then underwent L2 corpectomy with diskectomy, bilateral L1-L2, L2-L3 foraminotomy, L1-L2 and L2-L3 arthrodesis with instrumentation using expandable titanium cage and packed with in situ autograft and open reduction of kyphotic deformity. The final diagnosis was documented as L2 burst fracture with kyphotic deformity. What are the correct diagnosis and procedure code assignments? ...

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