Posterior Cervical Laminectomy

CPT 63015
Approach Open
Add-on / Variant CPTs
  • 63017 — Laminectomy, cervical, more than 2 segments
  • 63045 — Laminotomy with foraminotomy, single level
  • 22600 — Posterior cervical arthrodesis (if fusion added)
Preoperative Diagnosis:

Cervical stenosis with myelopathy / cervical radiculopathy

Postoperative Diagnosis:

Same

Procedure Performed:

Posterior cervical laminectomy [C3-C6 / specify levels] [with / without] instrumented fusion

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient prone in Mayfield 3-pin fixation with cervical spine in neutral alignment. Intraoperative fluoroscopy and neuromonitoring (SSEP/MEP) used.

Indications:

Patient presents with [cervical myelopathy / multilevel radiculopathy] refractory to conservative management. MRI demonstrates [multilevel stenosis / OPLL / hypertrophied ligamentum flavum] at [C3-C6 / specify]. T2 signal change in cord at [level]. [SSEP/MEP] baselines established. Risks including infection, CSF leak, neurological deterioration, hardware failure, and post-laminectomy kyphosis (if fusion not performed) discussed. Consent obtained.

Findings:

Midline posterior approach to the cervical spine. Laminae identified from [C3-C6]. Ligamentum flavum hypertrophied at [levels]. Dura decompressed after laminectomy. Pulsatile dural movement confirmed at completion.

Description of Procedure:

The patient was positioned prone in Mayfield 3-pin fixation after induction. Neuromonitoring baselines recorded. Lateral fluoroscopy confirmed appropriate cervical alignment. The posterior neck was prepped and draped in sterile fashion.
A midline longitudinal incision was made from [C2 to C7]. Subperiosteal dissection of the paraspinal muscles was carried bilaterally to the lateral masses. Self-retaining retractors placed. Fluoroscopy confirmed levels. The spinous processes were removed with Leksell rongeur. The laminae were thinned with a high-speed drill and removed using Kerrison rongeurs bilaterally from [C3-C6]. Ligamentum flavum was sharply removed. The dura was decompressed and pulsatile motion confirmed.
[Bilateral foraminotomies were performed at [C5-6 / levels] using 2-mm Kerrison rongeur to address foraminal stenosis.]
[For instrumented fusion:] Lateral mass screws were placed bilaterally at [C3-C6] using the An technique. Rod cut to length and secured. Bone graft applied to decorticated lateral masses. Fluoroscopic confirmation of hardware position.
The wound was irrigated copiously. Muscle and fascia closed in layers. Skin closed with staples. Cervical collar applied. Patient tolerated the procedure well.

Complications:

None

Specimens:

Ligamentum flavum / disc material

Estimated Blood Loss:

[X] mL

Drains:

[Wound drain placed / None]

Disposition:

Patient extubated in OR. Taken to neurosurgical ICU/floor in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Cervical stenosis with [myelopathy / radiculopathy], ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Posterior cervical laminectomy, ***, [with / without] instrumented fusion
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with cervical [myelopathy / multilevel radiculopathy] refractory to conservative management. MRI demonstrates multilevel stenosis / OPLL / hypertrophied ligamentum flavum at ***. T2 cord signal change at ***. SSEP/MEP baselines established. Risks including infection, CSF leak, neurological deterioration, hardware failure, and post-laminectomy kyphosis were discussed. Informed consent obtained.

FINDINGS: Posterior cervical spine exposed *** to ***. Ligamentum flavum hypertrophied at [levels]. After laminectomy, dura decompressed with pulsatile dural movement confirmed. [Foraminotomies performed at ***.]

DESCRIPTION OF PROCEDURE:
Patient positioned prone in Mayfield 3-pin fixation. Neuromonitoring baselines recorded. Lateral fluoroscopy confirmed cervical alignment. Midline incision from *** to ***. Subperiosteal dissection bilaterally to lateral masses. Self-retaining retractors placed. Fluoroscopy confirmed levels. Spinous processes removed with Leksell rongeur. Laminae thinned with high-speed drill and removed with Kerrison rongeurs from ***. Ligamentum flavum sharply excised. Dural pulsatility confirmed. [Bilateral foraminotomies at *** with 2-mm Kerrison.] [Instrumented fusion: lateral mass screws placed bilaterally at *** using An technique; rod secured; bone graft applied to decorticated lateral masses; fluoroscopic confirmation.] Wound irrigated. Muscle and fascia closed in layers. Skin closed with staples. Cervical collar applied. Neuromonitoring stable throughout. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Ligamentum flavum / disc material
COMPLICATIONS: None
DRAINS: [Wound drain / None]
DISPOSITION: Patient extubated in OR. Taken to neurosurgical ICU/floor in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Laminoplasty (open-door or French-door)

Motion-preserving alternative to laminectomy and fusion. Document hinge side, opening size, mini-plate fixation, and graft placement.

Laminotomy/foraminotomy only

For single-level foraminal stenosis without global stenosis. CPT 63045. Document hemilaminotomy, medial facetectomy, and nerve root decompression.

Charting Tips
  • Document neuromonitoring. Any signal changes intraoperatively must be documented.
  • State exact levels decompressed. This drives CPT coding.
  • Note ligamentum flavum removal and dural pulsatility as markers of adequate decompression
  • If fusion added, document lateral mass screw technique (An vs Magerl) and rod construct
  • Document cervical alignment maintained (kyphosis risk with laminectomy alone)
Billing Tips
  • Bill 63045 for posterior cervical laminectomy with foraminotomy at a single level (17.50 wRVU, 90-day global). Bill 63046 for thoracic laminectomy (16.82 wRVU). Bill 63047 for lumbar laminectomy (14.99 wRVU).
  • Each additional level of laminectomy is billed with add-on codes: 63048 for each additional cervical, thoracic, or lumbar level (+3.40 wRVU per level, no modifier -51 needed). Document each level decompressed.
  • When posterior fusion is performed at the same setting, bill the fusion codes in addition to the decompression. They are not bundled. Posterior instrumentation (22840-22842) and bone graft codes apply.
  • 90-day global period: physical therapy, collar management, and routine wound checks are bundled. Wound dehiscence or infection requiring return to OR uses modifier -78.
  • IONM is separately billable when a separate neurophysiology team monitors. Document baseline and intraoperative changes. Any motor evoked potential changes must be documented in real time.