Lumbar Spinal Fusion (TLIF / PLIF)

CPT 22633
Approach Open
Add-on / Variant CPTs
  • 22634 — Arthrodesis, posterior interbody, additional interspace (add-on)
  • 22842 — Posterior segmental instrumentation, 3–6 vertebral segments
Preoperative Diagnosis:

[L4-5 / L5-S1 / multilevel] degenerative disc disease with [spondylolisthesis / stenosis / instability], refractory to conservative management, requiring surgical stabilization

Postoperative Diagnosis:

Same

Procedure Performed:

[L4-5 / L5-S1] posterior spinal fusion with [TLIF / PLIF] interbody cage and posterior segmental instrumentation, [X] levels

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal with intraoperative neuromonitoring (IONM): [MEP/SSEP / EMG]

Indications:

The patient is a [age]-year-old [male/female] with [L4-5 degenerative spondylolisthesis Grade I / multilevel degenerative disc disease / isthmic spondylolisthesis] presenting with [axial low back pain / neurogenic claudication / radiculopathy] refractory to [X months] of conservative management. Imaging demonstrates [Grade I spondylolisthesis / disc collapse / foraminal stenosis]. Surgical stabilization and decompression were indicated. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

The operative levels were confirmed fluoroscopically. Decompression of the [L4-5 / L5-S1] levels demonstrated [thickened ligamentum flavum / facet hypertrophy / disc herniation compressing the traversing root]. Post-decompression, the [L5 / S1] nerve roots were freely mobile. The interbody space accepted a [X]-mm × [X]-mm interbody cage filled with [autograft / allograft / bone morphogenetic protein (rhBMP-2)].

Description of Procedure:

The patient was positioned prone on a Jackson table with the abdomen free. IONM was established. Fluoroscopy confirmed the operative levels with a localizing needle.

A midline posterior incision was made over [L4–S1]. The lumbodorsal fascia was incised. Paraspinal muscles were elevated subperiosteally to the facet joints bilaterally. Self-retaining retractors were placed.

Pedicle screws were placed bilaterally at [L4] and [L5/S1] under fluoroscopic guidance: [4.5–5.5 mm × X mm] screws. Electromyographic stimulation confirmed no medial wall breach ([>10 mA] threshold met). Rods were provisionally placed.

Laminectomy [/ laminotomy] was performed at [L4-5 / L5-S1], the ligamentum flavum was removed, and bilateral lateral recess decompression was performed. On the [right / left TLIF] side, a facetectomy was performed, and the nerve root was retracted. The disc space was prepared with sequential disc shavers and rasps to [X] mm height. The endplates were decorticated to bleeding bone.

A [PEEK / titanium expandable] interbody cage [X mm × X mm] packed with [local autograft / iliac crest / rhBMP-2 / allograft] was inserted under fluoroscopic guidance and confirmed in good position. Compression was applied across the construct. Decortication of the posterior elements was performed and [local autograft / allograft] was placed for posterolateral fusion.

IONM signals were stable throughout. Final fluoroscopy confirmed screw position, interbody cage position, and spondylolisthesis reduction [if applicable]. The wound was irrigated. Fascia was closed with [0-PDS]. Skin was closed with [2-0 Vicryl / staples].

Complications:

None

Specimens:

Disc material and ligamentum flavum sent to pathology

Estimated Blood Loss:

[X] mL

Drains:

[Hemovac drain in wound]

Disposition:

The patient was taken to the PACU in stable condition. Neurological status was assessed. Ambulation was initiated on postoperative day 1. DVT prophylaxis was initiated.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: L*** *** with spondylolisthesis/stenosis/instability
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: L*** posterior fusion with TLIF/PLIF interbody, PSI *** levels
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General + IONM (MEP/SSEP/EMG)

INDICATIONS: .PTAGE-year-old .PTSEX with L*** ***, failed conservative treatment *** months. Consent obtained.

FINDINGS: Level confirmed fluoro. Decompression: *** root freely mobile. Interbody: *** × *** mm cage, *** graft.

PROCEDURE:
Prone, Jackson table, abdomen free. IONM established. Level confirmed with needle. Midline incision L***–***. Fascia incised. Paraspinals elevated to facets. Pedicle screws *** × *** mm bilateral L*** and ***. EMG: threshold >10 mA, no breach. Rods provisionally placed. [Laminectomy/laminotomy], ligamentum flavum removed, bilateral decompression. [TLIF: facetectomy ***, root retracted, disc prep to *** mm, endplates decorticated.] *** cage inserted. Compression applied. Posterolateral autograft placed. IONM stable. Final fluoro: screws/cage appropriate, [spondylolisthesis reduced]. Irrigated. Fascia 0-PDS. Closed.

EBL: *** mL
COMPLICATIONS: None
DISPOSITION: PACU, neuro check. Ambulat POD 1.

Signed: .ME, .MYDEGREE
.TODAY
Variants

MIS-TLIF (Tubular Retractor)

Minimally invasive TLIF was performed via bilateral tubular retractors (METRx / X-Tube system). The paraspinal muscles were dilated rather than stripped. Pedicle screws were placed percutaneously through stab incisions under fluoroscopic guidance using a [Jamshidi needle / Longitude system]. The tubular retractor on the TLIF side allowed hemifacetectomy and interbody preparation. Rods were passed percutaneously through the percutaneous screw extenders. MIS-TLIF reduces paraspinal muscle injury, blood loss, and hospital stay compared to open fusion; exposure is limited and requires fluoroscopic proficiency.

Charting Tips
  • Document IONM baselines and any changes. Intraoperative neuromonitoring changes (>50% amplitude drop in MEPs, >10% latency change in SSEPs) are a surgical emergency. Document the baseline, any changes, and response. Stable IONM throughout provides important legal protection.
  • Document pedicle screw placement confirmation method (fluoroscopy, O-arm CT, or EMG stimulation). A screw with medial wall breach can injure the nerve root. Document 'EMG >10 mA, no medial breach' or 'O-arm confirmed satisfactory position' for each screw.
  • Document spondylolisthesis reduction if applicable. Grade I spondylolisthesis is often reduced with compression/distraction maneuvers. Document pre- and post-reduction slip grades (percentage slip) to confirm correction and establish that reduction occurred.
Billing Tips
  • Approach determines the primary code: 22612 (posterior/PLIF, 22.94 wRVU), 22630 (TLIF, 21.54 wRVU), 22558 (ALIF, 22.94 wRVU), 22633 (combined anterior + posterior at same level, 26.13 wRVU). Document approach explicitly.
  • Each additional interspace: 22614 add-on (posterior), 22632 add-on (TLIF), 22585 add-on (ALIF, 5.38 wRVU), 22634 add-on (combined, 7.76 wRVU). Bill one add-on per additional level fused.
  • Instrumentation (pedicle screws, rods) is separately billable: 22840 (posterior non-segmental, 12.21 wRVU), 22842 (posterior segmental 3–6 vertebrae, 12.25 wRVU), 22843 (7+ vertebrae, 13.10 wRVU). Document number of levels instrumented.
  • Bone graft: autograft harvest (20937/20938) separately billable if harvested from a separate incision; local autograft from the surgical site is bundled.
  • Global period is 90 days. Post-op X-rays, wound checks, and brace management are bundled. Return to OR for hardware complication uses modifier -78.
  • Two-surgeon billing: when an access surgeon opens the retroperitoneal/transperitoneal corridor for ALIF and a spine surgeon performs the fusion, both bill with modifier -62 (co-surgery). Document each surgeon's distinct role.
  • Document: number of levels, approach, interbody device type (cage brand), graft material, number of screws/rods, neuromonitoring use, and intraoperative imaging. All of these support coding and implant log requirements.