Lumbar Discectomy (Microdiscectomy)
Right [left] L[4-5 / 5-S1] disc herniation with [radiculopathy / neurogenic claudication / cauda equina syndrome], confirmed on MRI
Same
Right [left] L[X–X] microdiscectomy [/ bilateral decompression]
[***, MD/DO]
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male / female] with right [left] [L4/L5 / L5/S1] radiculopathy refractory to [X weeks] of conservative management including physical therapy and epidural steroid injections. MRI demonstrates [posterolateral / central] disc herniation at [L4-5] compressing the [L5] traversing nerve root [/ posterolateral disc herniation at L5-S1 compressing the S1 traversing root / foraminal herniation at L4-5 compressing the exiting L4 root / foraminal herniation at L5-S1 compressing the exiting L5 root]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Intraoperatively, a [large / moderate] [posterolateral / central / foraminal] disc herniation was identified at [L4-5 / L5-S1] compressing the [L5 / S1] traversing nerve root [/ exiting L4 root at the L4-5 foramen / exiting L5 root at the L5-S1 foramen]. Following discectomy, the nerve root was decompressed and freely mobile. No epidural hematoma or instability was encountered.
The patient was positioned prone on a [Wilson frame / Jackson table] with the abdomen free. Fluoroscopy was used to confirm the operative level by needle localization prior to incision. [L4-5 / L5-S1] confirmed.
A [2–3]-cm midline incision was made centered over [L4-5 / L5-S1]. The lumbodorsal fascia was incised. The paraspinal muscles were subperiosteally elevated and retracted with a self-retaining retractor. The [L4-5 / L5-S1] interlaminar space was identified. Under loupe magnification [/ operating microscope], the ligamentum flavum was incised and removed with Kerrison rongeurs. A medial [L4 / L5] laminotomy was performed as needed.
The nerve root was identified and gently retracted medially with a nerve root retractor. The disc herniation was identified in the lateral recess / subligamentous position. The posterior longitudinal ligament was incised with a [#11 long-handled blade / angled curette]. The disc fragment was removed with pituitary rongeurs. A [3-mm] curette was used to probe the disc space: [residual loose fragments were removed / no further fragments identified]. Hemostasis was achieved with bipolar cautery and [Gelfoam / Surgicel].
Following decompression, the nerve root was freely mobile with no residual compression. The wound was irrigated. Fascial closure was performed with [0-Vicryl]. Skin was closed with [2-0 Vicryl / 3-0 Monocryl].
None
Disc material sent to pathology
[X] mL
None
The patient was taken to the PACU in stable condition. Neurological status was checked in the recovery room. Ambulation was initiated on the same day. The patient was discharged home [/ on postoperative day 1].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left L*** disc herniation with radiculopathy
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left L*** microdiscectomy
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: .PTAGE-year-old .PTSEX with L*** radiculopathy, failed conservative management *** weeks. MRI: *** herniation at L***, *** root compression. Consent obtained.
FINDINGS: *** posterolateral/central disc herniation at L***, compressing *** root. Post-discectomy: root freely mobile.
PROCEDURE:
Prone on Wilson frame/Jackson table. Fluoroscopic level confirmation: L*** confirmed. *** cm midline incision. Fascia incised. Paraspinals elevated. Interlaminar space identified. Ligamentum flavum removed, Kerrison. [*** laminotomy.] Loupes/microscope. Nerve root identified, gently retracted medially. Herniation identified ***. PLL incised with #11 blade. Fragment removed with pituitary rongeurs. Disc space probed; no residual. Hemostasis bipolar/Gelfoam. Root freely mobile. Irrigated. Fascia 0-Vicryl. Skin closed.
EBL: *** mL
SPECIMENS: Disc to pathology
COMPLICATIONS: None
DISPOSITION: Neuro check PACU. Ambulated same day. DC home.
Signed: .ME, .MYDEGREE
.TODAYVariants
Cauda Equina Syndrome: Emergency Decompression
Given acute cauda equina syndrome (saddle anesthesia, bowel/bladder dysfunction), emergent surgical decompression was performed. A bilateral laminectomy was performed to allow bilateral nerve root decompression. A large central disc herniation was encountered and removed. Post-operatively, neurologic function was reassessed. Cauda equina syndrome from disc herniation requires emergency surgery; delays beyond 24–48 hours from symptom onset are associated with permanent sphincter dysfunction. Document the time from symptom onset to surgical decompression in the operative note. ICD-10: add G83.4 (cauda equina syndrome) as a secondary diagnosis code.
Bilateral Decompression: Over-the-Top Technique
For central stenosis with bilateral symptoms, a unilateral approach with over-the-top bilateral decompression was performed. The ipsilateral laminotomy was extended and the operating table was tilted to allow retraction of the dural sac and decompression of the contralateral lateral recess and foramen. This technique preserves the midline ligamentous structures (supraspinous, interspinous) and avoids bilateral facet removal, reducing instability risk compared to full laminectomy.
Charting Tips
- Document fluoroscopic level confirmation before incision. Wrong-level surgery is one of the most common surgical never events in spine surgery. The operative note must explicitly state that fluoroscopy confirmed the operative level before skin incision.
- Document the extent of laminotomy and facet joint preservation. Removing more than 50% of a facet joint creates instability requiring fusion. Document how much facet was removed and confirm that >50% was preserved on each side.
- Document post-decompression nerve root mobility. After discectomy, explicitly state that the nerve root was 'freely mobile without residual compression.' This confirms adequate decompression and establishes the clinical endpoint of the operation.
- Foraminal vs. posterolateral herniation root pairing: for a posterolateral (paracentral) herniation, the compressed root is the traversing (descending) root at that disc level (L4-5 disc = L5 root; L5-S1 disc = S1 root). For a far-lateral or foraminal herniation, the compressed root is the exiting root one level up (L4-5 foramen = exiting L4 root; L5-S1 foramen = exiting L5 root). Document specifically which root was decompressed and which herniation pattern was present.
- ICD-10: M51.16 (intervertebral disc disorder with radiculopathy, lumbar region, for discs at L1-L4 levels), M51.17 (lumbosacral, for L5-S1 disc level), M54.16 (radiculopathy, lumbar region), M54.17 (radiculopathy, lumbosacral region), G83.4 (cauda equina syndrome — use as secondary diagnosis for acute cauda equina presentations requiring emergent decompression).
Documentation & Reimbursement Considerations
- Report Lumbar Discectomy (Microdiscectomy) as the primary service when it is the definitive operation performed.
- Both open and tubular/minimally invasive approaches use the same reporting options — surgical approach does not change reporting selection.
- Do not report the service with the primary service at the same session — they are mutually exclusive for a given level.
- Bilateral lumbar discectomy at the same level uses bilateral-procedure reporting (one line item with bilateral-procedure reporting appended; Medicare reimburses at 150% of unilateral allowable). Do not use multiple-procedure reporting or submit two separate line items for bilateral procedures at the same level.
- Decompression performed in excess of what is required for fusion access requires distinct-service reporting (not multiple-procedure reporting) with explicit documentation that neural decompression was performed beyond the fusion exposure. Multiple-procedure reporting does not unbundle NCCI edits.
- Document preoperative MRI correlation with intraoperative findings: level confirmed by fluoroscopy before incision, nerve root identified and decompressed, disc fragment description (size, location, extruded vs. contained). These details are essential for medicolegal defense and medical necessity support.