CPT® Code 0274T

1. Indications

The percutaneous laminotomy or laminectomy procedure is indicated for various conditions that result in neural compression. The following are explicitly provided indications for this procedure:

• Herniated Discs - The presence of ruptured disc fragments or bulging nucleus pulposus that compresses spinal nerves or the spinal cord.
• Spinal Stenosis - Narrowing of the spinal canal that can lead to pressure on neural elements.
• Bone Spurs - Osteophytes that may develop on the vertebrae and contribute to nerve compression.
• Ligamentous Hypertrophy - Thickening of the ligamentum flavum that can encroach upon the spinal canal.

2. Procedure

The procedure involves several detailed steps to ensure effective decompression of neural elements:

• Preoperative Imaging - Prior to the procedure, a preoperative MRI, CT, or myelography is performed to identify the target entry site over the spine. This imaging is crucial for planning the surgical approach and ensuring accurate targeting of the affected area.
• Accessing the Interlaminar Space - Under indirect image guidance, such as fluoroscopy or CT, a guiding portal and inner trocar are inserted percutaneously. The entry point is typically located inferior to the vertebral segment being decompressed and lateral to the spinous process margin.
• Advancing the Trocar - The guiding portal and inner trocar are advanced toward the inferior vertebral segment lamina, navigating toward the border of the interlaminar space while utilizing imaging guidance for precision.
• Creating the Access Portal - Once the inner trocar is removed, a hollow access portal remains in the interlaminar space. This portal is secured against the skin surface using plate and guide devices, which help ensure the proper placement of surgical instruments.
• Bone Sculpting - A bone sculptor is advanced through the portal to the free edge of the lamina. Small pieces of bone are removed from the superior and inferior lamina, effectively performing the laminotomy or laminectomy.
• Resecting Ligamentum Flavum - After enlarging the interlaminar space, the bone sculptor is removed, and a tissue sculptor is advanced through the portal. The ligamentum flavum is resected as necessary to relieve pressure on the neural elements.
• Foraminotomy - The openings under the facet joints, where the nerve roots exit, are examined. If needed, a portion of the bone around these openings may be removed to provide additional pressure relief (foraminotomy).
• Decompressing Nerve Roots - Any ruptured disc fragments or bulging nucleus pulposus are removed to decompress the affected nerve(s). This step is critical for alleviating pain and restoring function.
• Confirming Decompression - The effectiveness of the decompression is visually confirmed by observing changes in the epidurogram and the flow of contrast material injected during the procedure.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any immediate complications and assessing the effectiveness of the decompression. Patients may experience some discomfort at the site of the procedure, which can be managed with appropriate pain relief measures. Follow-up imaging may be required to evaluate the success of the decompression and to ensure that no further intervention is necessary. The recovery process typically involves a gradual return to normal activities, with specific instructions provided by the healthcare provider regarding activity restrictions and rehabilitation exercises to promote healing and restore function.