AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2024 Issue 1; Ask the Editor

Postlaminectomy Lumbar Spondylolisthesis

A patient who recently had lumbar decompression surgery was readmitted with progressive worsening of low back pain radiating down both legs. The patient was diagnosed with dynamic instability, lumbar spondylolisthesis, and cauda equina syndrome prompting further surgery. During this admission, the patient underwent an L4-S1 transforaminal lumbar interbody fusion (TLIF) with posterior instrumentation. Following the TLIF procedure, the patient continued to experience bilateral parasthesias with impaired sensation and the provider documented postlaminectomy syndrome. A query was submitted to determine the cause of the spondylolisthesis. The provider’s response to the query stated, “The spondylolisthesis occurred in the postoperative period after a decompression/laminectomy surgery secondary to multiple factors, including the decompression surgery which weakened the posterior tension band, patient’s weight and obesity causing extra stress.” Is postlaminectomy lumbar spondylolisthesis reported as a postoperative complication or as a postlaminectomy syndrome? ...

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