CPT® Code 21616

1. Indications

The procedure described by CPT® Code 21616 is indicated for specific conditions that may require the excision of the first rib and/or cervical rib along with a sympathectomy. These indications may include:

• Thoracic Outlet Syndrome - A condition characterized by compression of the nerves or blood vessels in the thoracic outlet, which can lead to pain, numbness, and weakness in the arms.
• Cervical Rib Syndrome - A condition where an extra rib is present, which can cause similar symptoms as thoracic outlet syndrome due to compression of surrounding structures.
• Persistent Pain - Chronic pain in the neck, shoulder, or arm that has not responded to conservative treatments may warrant this surgical intervention.

2. Procedure

The procedure for CPT® Code 21616 involves several critical steps that ensure the successful excision of the rib and the performance of a sympathectomy. The steps are as follows:

• Step 1: Anesthesia Administration - The patient is placed under general anesthesia to ensure they are completely unconscious and free from pain during the procedure.
• Step 2: Incision Creation - The surgeon makes a precise incision over the clavicle, which provides access to the first rib and/or cervical rib that needs to be excised.
• Step 3: Rib Isolation - The physician carefully isolates the rib from the surrounding tissues, ensuring that all necessary structures are protected during the excision.
• Step 4: Rib Excision - Using surgical saws and other specialized instruments, the surgeon removes the rib from its articulation, which is the joint where the rib connects to the spine.
• Step 5: Sympathectomy (if applicable) - If indicated, the sympathetic nerve pathway is severed to alleviate symptoms associated with nerve compression.
• Step 6: Site Irrigation - The surgical site is thoroughly irrigated to clean the area and minimize the risk of infection.
• Step 7: Closure of Incisions - Finally, the incisions made during the procedure are closed using sutures or other closure methods to promote proper healing.

3. Post-Procedure

After the completion of the procedure described by CPT® Code 21616, patients can expect specific post-operative care and recovery considerations. It is essential to monitor the surgical site for any signs of infection or complications. Patients may experience pain and discomfort in the area of the incision, which can be managed with prescribed pain medications. Physical therapy may be recommended to aid in recovery and restore mobility in the affected arm and shoulder. Follow-up appointments will be necessary to assess healing and address any concerns that may arise during the recovery process. Patients should be advised to avoid strenuous activities and heavy lifting until cleared by their healthcare provider.