CPT® Code 61516

1. Indications

The procedure described by CPT® Code 61516 is indicated for the following conditions:

• Supratentorial cysts - These are fluid-filled sacs located in the supratentorial region of the brain that may require surgical intervention due to symptoms or complications.
• Brain abscesses - Although primarily associated with CPT® Code 61514, the presence of a brain abscess may necessitate similar surgical approaches for excision or drainage.
• Increased intracranial pressure - Conditions leading to elevated pressure within the skull may warrant the removal or drainage of cysts to alleviate symptoms.
• Neurological deficits - Symptoms such as seizures, headaches, or other neurological impairments that arise from the presence of a cyst may indicate the need for this procedure.

2. Procedure

The procedure for CPT® Code 61516 involves several critical steps to ensure effective treatment of the cyst.

• Step 1: Anesthesia and Positioning - The patient is placed under general anesthesia to ensure comfort and immobility during the procedure. Proper positioning of the patient is crucial for optimal access to the supratentorial region.
• Step 2: Scalp Flap Creation - A scalp incision is made, and scalp flaps are created to expose the underlying skull. This involves careful dissection to preserve the blood supply to the scalp.
• Step 3: Burr Hole Drilling - Burr holes are drilled into the skull to facilitate access to the brain. These holes are strategically placed to allow for the subsequent cutting of the bone.
• Step 4: Bone Flap Elevation - The bone between the burr holes is cut using a surgical saw or craniotome. A bone flap is then elevated and removed, providing access to the brain tissue beneath.
• Step 5: Cyst Excision or Fenestration - The cyst is either excised or fenestrated. If excised, the cyst is carefully dissected from surrounding brain tissue and removed in its entirety. If fenestrated, an incision is made in the cyst to create an opening for drainage into the cerebrospinal fluid pathway.
• Step 6: Dura Mater Repair - After the cyst has been addressed, the dura mater is repaired to restore the protective covering of the brain.
• Step 7: Bone Flap Repositioning - The previously removed bone flap is repositioned over the dura and secured using steel sutures. Alternatively, the skull defect may be filled with bone wax or silicone to ensure stability.
• Step 8: Scalp Closure - Finally, the scalp flap is reapproximated, and the skin incision is closed using sutures or staples, completing the surgical procedure.

3. Post-Procedure

Post-procedure care following CPT® Code 61516 involves monitoring the patient for any signs of complications, such as infection or bleeding. Patients may require imaging studies to assess the surgical site and ensure proper healing. Pain management is also an essential aspect of post-operative care, and patients may be prescribed analgesics as needed. Rehabilitation services may be recommended depending on the patient's neurological status and recovery progress. Follow-up appointments are crucial to evaluate the surgical outcome and address any ongoing symptoms or concerns.