Posterior Cervical Laminectomy
Cervical stenosis with myelopathy / cervical radiculopathy
Same
Posterior cervical laminectomy [C3-C6 / specify levels] [with / without] instrumented fusion
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
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]. Cervical alignment [lordotic / neutral / kyphotic — fusion required if kyphotic]. [SSEP/MEP] baselines established. Risks including infection, CSF leak, neurological deterioration, C5 nerve root palsy (5-11% incidence with laminectomy+fusion), hardware failure, adjacent segment disease, and post-laminectomy kyphosis (if fusion not performed) discussed. Consent obtained.
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.
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.
None
Ligamentum flavum [/ bone fragment to pathology if indicated]
[X] mL
[Wound drain placed / None]
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 [/ bone fragment if indicated]
COMPLICATIONS: None
DRAINS: [Wound drain / None]
DISPOSITION: Patient extubated in OR. Taken to neurosurgical ICU/floor in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Laminoplasty (open-door or French-door)
Motion-preserving alternative. Requires lordotic or neutral alignment — contraindicated with >13 degrees of kyphosis or significant preoperative axial neck pain. Open-door (Hirabayashi) technique: lamina completely cut on open side, greenstick fracture hinge on contralateral side (one hinge). French-door (Kurokawa) technique: midline spinous process split with bilateral hinges at the lamina-facet junction (two hinges). Document which technique, hinge side for open-door, opening size, mini-plate fixation, and whether graft placed in the gutter.
Laminotomy/foraminotomy only
For single-level foraminal stenosis causing radiculopathy, without global central stenosis. Document hemilaminotomy, medial facetectomy extent, and nerve root decompression confirmed.
Charting Tips
- State the exact levels decompressed and whether facetectomy or foraminotomy was performed at each level. The number of segments and the extent of foraminal decompression determine code selection.
- Note ligamentum flavum removal and dural pulsatility as markers of adequate decompression
- Document cervical alignment: lordotic alignment maintained (laminoplasty and laminectomy-alone require lordosis; fusion locks in alignment, good or bad)
- If fusion added, document lateral mass screw technique (An, Magerl, or Roy-Camille — specify which) and rod construct; document bilateral vs. unilateral
- Document neuromonitoring baseline and any intraoperative signal changes — MEP/SSEP changes require immediate documentation and response protocol
- C5 palsy (5-11% with laminectomy+fusion): document baseline deltoid and biceps strength preoperatively; any new postoperative weakness should be charted against this baseline
Documentation & Reimbursement Considerations
- Primary service: Report Posterior Cervical Laminectomy as the primary service when it is the definitive operation performed.
- For central decompression without facetectomy or foraminotomy, one code covers all levels decompressed, selected by extent (1–2 cervical segments, 17.17 wRVU, or more than 2 segments, 20.33 wRVU, both 90-day global). The per-segment code (17.50 wRVU) requires laminectomy plus facetectomy plus foraminotomy at that segment and is not appropriate for multilevel central decompression alone. Its add-on for each additional segment (3.38 wRVU) can only follow that per-segment code.
- Single-level posterior laminoforaminotomy for radiculopathy (hemilaminotomy, medial facetectomy, and nerve root decompression without full laminectomy) has its own code (14.54 wRVU, 90-day global), separate from the per-segment laminectomy with facetectomy and foraminotomy.
- Laminoplasty is reported by whether reconstruction with bridging graft and mini-plate fixation is performed (21.46 vs. 24.87 wRVU). The reconstruction code includes the mini-plates, so do not additionally report posterior instrumentation or fusion for the same laminoplasty levels.
- When posterior fusion is added, report the fusion in addition to the decompression because they are not bundled. Posterior cervical arthrodesis is reported for the first segment (16.97 wRVU) with an add-on for each additional segment (6.27 wRVU). Lateral mass screw constructs are segmental instrumentation, reported by the number of segments spanned (12.25 wRVU for 3–6 segments), not as non-segmental fixation.
- 90-day global period: physical therapy, collar management, and routine wound checks are bundled. IONM is reported by the monitoring provider, not the surgeon. Any MEP/SSEP changes must be documented in real time in the operative note.