1.OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:L5-S1 herniated disc

POSTOPERATIVE DIAGNOSIS:Same.

OPERATION:L5-S1 discectomy and L5 nerve root decompression

INDICATIONS FOR SURGERY: The patient is a 53 year old male who has a history of low back pain and left leg pain in the L5 distribution.An MRI shows the presence of a herniated disc at L5-S1 migrated up impinging the L5 nerve root on the left side.The patient has been treated conservatively without any improvement.

PROCEDURE:The patient was intubated and placed in prone position. Then an incision was marked on the lower back and was prepped and draped in a sterile fashion.The incision was made with a #10 scalpel, Bovie coagulator and down to the fascia.At this point, the fascia was incised with a #15 blade.A flap of fascia was then retracted with #2-0 Vicryl and the muscle was gently dissected and retracted with a Taylor retractor.Under the microscope, a curette was placed between the L5-S1 and x-rays were obtained.The x-rays showed that the curette was between L5 and S1 until under the microscope with microdissection, and with the use of a Midas Rex the lamina of L5 was partially drilled off and yellow ligament was opened, removed, and then the L5 nerve root was identified.A large herniated disc was then found, removed and the L5 nerve root was completely decompressed.At this point, the interspace at L5-S1 was entered and the disc removed laterally, and then a complete decompression of the L5 into the foramen was accomplished.At this point, the area was irrigated with antibiotic solution and a paste of Depo-Medrol, Amicar, and morphine was left in place.The fascia was closed with a #2-0 Vicryl, subcutaneous tissue with a #3-0 Vicryl, and the skin was closed with subcuticular #4-0 Vicryls.

What is the CPT Codes and indexing path ????