Spinal injuries services

SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 SPECIALISED SERVICES NATIONAL DEFINITIONS SET (THIRD EDITION 2008)

Specialised Spinal Services (all ages) - Definition No. 6
Preface
This definition is part of the third edition of the Specialised Services National Definitions Set
(SSNDS) being produced over 2008/10. The SSDNS was last edited in 2002. During 2008/10
each of the definitions in the second edition of the SSNDS will be updated; in addition three new
definitions will be added to the Set.
Each definition is drawn up by a process involving providers (clinicians, hospital managers, and
information and coding staff), commissioners and patients’ groups and is then endorsed wherever
possible by relevant national organisations. Finally, when the definition has been signed off by
the Department of Health (DH) and the National Specialised Commissioning Group it is
published on their websites.
The purpose of a definition is to identify the activity that should be regarded as specialised and
therefore within the remit of PCT collaborative commissioning. A service is specialised if the
planning population (i.e. catchment area) for that service is greater that one million people. This
means that a specialised service would not be provided by every hospital in England; generally, it
would be provided by less than 50 hospitals.

The definitions are not prescribed service models nor do they set service standards. Where
national standards for a specialised service already exist, these may be referred to in the
definition.
Inclusion of a treatment or intervention in a definition should not be taken to mean that there is
established evidence of clinical or cost effectiveness.
The production of the SSNDS is an iterative process. The content of individual definitions in the
SSNDS will inevitably change over time as new healthcare services which are specialised are
introduced into the NHS and other services, which were previously specialised, become
commonplace and cease to be considered specialised.
Future editions of the SSNDS will become more refined as the classifications systems develop
and become better able to categorise specialised service activity. The current classification
systems used in the third edition are the International Classification of Diseases, version 10, and
the OPCS Classification of Interventions and Procedures, version 4.
Comments and suggested improvements to the definitions are very welcome and can be sent to
the National Specialised Commissioning Group. Contact details are available from the NSCG
website: www.nscg.nhs.uk
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 This definition is divided into two parts:

Part I: Spinal cord injuries of traumatic and non-progressive non-traumatic origin

Part II: Complex spinal surgery including spinal deformity surgery and reconstructive
spinal surgery

SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009
Part I: Spinal cord injuries of traumatic and non-progressive non-traumatic origin

1. Introduction and general description of the spinal cord injury centre service

This part of the definition relates to activity undertaken within specialist spinal cord injury (SCI)
centres. The Annex lists the 8 SCI centres in England. Other providers (i.e. major trauma centres,
specialised spinal surgery centres, critical care units) handle significant spinal activity and early
liaison and agreed protocols with SCI centres will ensure seamless care and the avoidance of
unnecessary complications.
Specialised spinal cord injuries encompass any traumatic insult to the spinal column at cervical
(neck), thoracic (chest), thoracolumbar, lumbar, lumbo-sacral (lower back) or multiple levels
which causes complete or partial interruption of spinal cord function.
Such injuries will usually lead to some degree of neurological deficit such as loss of motor
function (weakness or paralysis), bowel and bladder function, and sensory or autonomic function
(control of blood pressure, etc.). In general the higher up the spine the trauma is inflicted the
more serious the degree of SCI. The resultant damage may be permanent, temporary or delayed.
SCI care incorporates the core components of acute care, restorative rehabilitation, reintegration
into the community and long term follow-up into a seamless clinical service.
The SCI service also includes the surgical and non-surgical stabilisation and rehabilitation of
patients with non-progressive spinal cord dysfunction arising from spinal cord pathology or
disease.
Malignant spinal tumours are included in Definition No.1, Specialised Cancer Services rather
than this definition. However if spinal cord dysfunction has arisen from the effects of a benign
tumour which has been primarily dealt with by an appropriate specialty, or from a tumour which
has been adequately treated and is now deemed to have a benign course, or if the patient has a
significant life expectancy, the patient may transfer to the SCI centre for rehabilitation and life-
long follow up.

2. Rationale for the service being included in the Specialised Services National Definitions
Set
Patients and the expertise needed to manage them are concentrated in relatively few specialist
centres. Spinal cord injury is a low volume, high cost service and results in multi-system
physiological impairment, dysfunction and the potential for complication. The management of
these patients therefore is multi-specialist and multi-disciplinary. Evidence shows that
management by a dedicated comprehensive team produces the best outcomes for patients (Smith,
M. (1999) ‘Making the difference-efficacy of specialist versus non-specialist management of
spinal cord injury’ Spinal Injuries Association, London) and the involvement of the specialist
team from the earliest point following injury through restoration and re-integration back into the
community is crucial to achieving good outcomes.
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009
3. Links to other services in the Specialised Services National Definitions Set
Definition No.4, Specialised Services for Women’s Health (adult) - Women with SCI may have special gynaecological and obstetric needs requiring liaison between the SCI centre and the patient’s local obstetric/gynaecology services. For men with SCI to father children often requires the application of assisted fertility techniques to their partner (i.e. specialised sub-fertility services). Definition No.5, Assessment and Provision of Equipment for People with Complex Physical Disabilities (all ages) - Relevant sections of this definition include: assisted locomotion and orthotics to improve mobility in paraplegics; assistive technology in the management of spinal cord injuries and environmental control systems to improve communication and quality of life for tetraplegics; and specialised equipment to improve mobility and communications. Definition No. 6, Specialised Spinal Services (all ages) - Part II: Complex spinal surgery including spinal deformity surgery and reconstructive spinal surgery Definition No.7, Specialised Rehabilitation Services for Brain Injury and Complex Disability (adult) - There is a degree of overlap between services covered by Definition No, 6 Part I, and Definition No. 7. Definition No.8, Specialised Neurosciences Services (adult) Definition No.23, Specialised Services for Children - The section in this definition on paediatric
neurosciences services includes complex disability, rehabilitation and neuropsychiatry. Children
with a SCI will require a multidisciplinary assessment and access to an appropriate specialist
spinal rehabilitation which is grounded on a close working relationship between the paediatrician
and the spinal specialist.
Definition No.29, Specialised Respiratory Services (adult)
Definition No.31, Specialised Pain Management Services (adult)
Definition No.34, Specialised Orthopaedic Services (adult)

4. Detailed description of specialised activity for spinal cord injuries of traumatic and non-
progressive non-traumatic origin

SCI centre services provide treatment and management of patients with traumatic injury to the
spinal cord or traumatic injury or disease to the spine which causes spinal cord impairment. All
services provided to SCI patients within a SCI centre should be regarded as specialised. Only half
the SCI centres provide spinal surgery on site and consequently much specialised spinal surgery
is carried out at other trusts with transfer to the SCI centre thereafter for management and
rehabilitation. Specialised spinal surgery services for spinal cord injured people are dealt in Part
II of this definition, which deals with all specialised spinal surgery.
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009
The predominant focus of the SCI centre is rehabilitation. The aim is to optimise the
independence of the spinal cord injured patient in relation to their medical condition (e.g. dealing
with skin, bladder and bowel problems), their mobility (e.g. provision of an appropriate
wheelchair) and their daily living (e.g. access to facilities in their home). This is achieved by the
following specialised services:
4.1 Surgical or non-surgical stabilisation of the unstable spine

This will take place at the SCI centre or another trust.
4.2 Care of the newly injured patient, including ventilatory support and bowel and bladder
management

The following services are an integral part of an SCI centre service unless otherwise stated:
 invasive and non invasive ventilatory support which may continue once the patient has been
discharged home in which case it will either be managed by a home ventilation team from the SCI or the local home ventilation team (Note: the relevant OPCS intervention codes: E42.1-E42.9 and E85.1-E85.9, do not distinguish between SCI patients and the many other non-SCI patients receiving ventilation.)  specialised treatment of spasticity/pain (e.g. Baclofen pumps)  neuroprosthetic implantation including phrenic pacing for restoring breathing artificially and sacral anterior root stimulator for bladder dysfunction and implanted systems to improve upper limb function in tetraplegia (Note: neuroprosthetic implantation may be carried out by a variety of clinicians including a neurosurgeon, an orthopaedic / spinal surgeon or an upper limb surgeon and ideally will take place at the SCI centre but may take place elsewhere.)  treatment for neurological conditions of the bowel; treatment is mainly non-surgical  treatment for neuropathic bladder; treatment is mainly non-surgical  tissue viability nursing and surgery for neurogenic patients  functional surgery (tendon transfer) for improvement of upper limb function in tetraplegics. (Note: functional surgery is likely to be carried out by specialists in hand or upper limb surgery and may or may not take place at the SCI centre.)
4.3 Re-admission of patients when they require hospitalisation for spinal cord related
complications
4.4 Admissions for non specialised (medical and surgical) services
Admissions for non specialised (medical and surgical) services to a SCI centre will be necessary
where the SCI patient has particular problems (e.g. skin problems, labile blood pressure) that
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 require specialist nursing expertise and facilities (e.g. to turn patients over and manage their
bowels and bladders) which would not be available in a local hospital.

4.5 Out-patient and outreach services to deal with the problems associated with spinal cord
dysfunction
SCI centre staff liaise with relatives, carers, general practitioners, district nurses and local
hospitals to facilitate the reintegration of the patient back into the community. In particular spinal
nurse specialist and therapists are involved in the long term reintegration of the spinal cord
injured patient into society and will visit the patient at home and train local staff in caring for the
specific needs of particular patients.
Outpatient clinics, often multidisciplinary, include clinics on pain, spasticity, urology, pressure
sores, hand function, gastro-intestinal, musculoskeletal and other system disorders arising from
the SCI. Some of these clinics may be provided by the SCI staff on an outreach basis at local
hospitals.
4.6 Sexual health function
Sexual health function services, including fertility diagnosis for the male patient and advice on
low technology interventions to achieve sexual function and fertility, are provided by SCI
centres. For men with SCI to father children often requires the combination of sperm retrieval
techniques, storage and application of assisted fertility procedures to the partner (see links to
Definition No.4, Specialised Services for Women’s Health). Women with SCI often have special
gynaecological and obstetric needs which would be dealt with by the patient’s local
obstetric/gynaecology services but may require liaison with the SCI centre.
4.6 Follow-up of patients with persistent spinal cord dysfunction

Structured and regular follow-up of patients with persistent spinal cord dysfunction for life will
be necessary in order to ensure good health, prevention of complications that require
hospitalisation, continuity of care and good quality of life. The optimum frequency of follow-up
will in part be dependent on the underlying lesions and on the self-care abilities of the patient.
The prevalent population with SCI is still accumulating and the physiological, medical and
disabling consequences of ageing and duration of paralysis pose increasingly complex
management problems.

5. Identifying and costing specialised spinal cord injury and spinal disease activity

5.1 Existing currencies
Currently currencies differ for each SCI centre trust/commissioner and do not necessarily
accurately reflect the costs of delivering the service. Currency examples include:
 bed days
 intensive care bed days
 average bed days inclusive of costs of out-patients
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009  daily supplement for ventilated bed days
 daily supplement for children
 procedure-based classifications developed internally by the provider
 out-patient attendances.

5.2 Costing activity

Please refer to the latest Department of Health Guidance on Payment by Results for up to date
information on national tariffs and activity included/excluded from tariff.
Please note that not all the Payment by Results inclusions and exclusions listed below are
specialised activity, but they are included here for completeness.
(i) In scope of 2009/10 Payment by Results and has national tariffs:
 day case and in-patient admitted patient care.
(ii) Excluded from 2009/10 Payment by Results therefore a local tariff is negotiated:
 rehabilitation out-patient attendances (Treatment Function Code:314)
 rehabilitation services (i.e. all activity taking place at one of the eight spinal injury centres)
 high cost drugs
 see also list of specific HRG exclusions.

5.3 Outstanding issues raised regarding currencies and classification systems
ICD codes and OPCS intervention codes are currently unable to capture SCI centre activity so
there is no standard currency which incorporates all SCI centre activity and for that reason most,
if not all SCI centre activity is outside Payment by Results and hence does not have a national
tariff. The codes that do exist for SCI centre activity largely apply to surgery (spinal, urological,
neurosurgical, etc) and do not capture the breadth of services provide by SCI centres. In
particular there are currently very few codes for non-surgical care, particularly rehabilitation,
which makes up the majority of care provided by a SCI centre.
The eight SCI centres in England are participating in a SCI Currencies Group chaired by the
South of England SCI Consortium which has been adopted by the Department of Health as a PbR
Development Site. The purpose of the work is to develop classifications (currencies) for the
future commissioning of the service. A set of classifications has been agreed against which SCI
centres have collected activity data for a period of six months which is then costed. The
classifications may be revised in the light of the costing information. The aim is to shadow the
new classifications against existing currencies in 2009/10. The latest version of the
Classifications (Proposal for Packages) developed by the SCI Currencies Group can be found on
http://www.secscg.nhs.uk/home/consortia/spinal-injuries/

Specialised spinal surgery is carried on both SCI patients and non spinal-cord-injured people
in hospitals other than SCI centres. It is therefore included in Part 2 of this definition. Some
procedures, such as fixation surgery, would be classified as specialised even if carried out on a
non-paralysed person but many other procedures/services which are clearly specialised when
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 provided to a paralysed patient would be considered routine when provided to a non paralysed patient. One possible approach might be to use the ICD codes G81(Hemiplegia), G82 (Paraplegia and Tetraplegia) and G83 (Other Paralytic Syndromes) to distinguish between surgery carried out on non-paralysed patients and surgery carried out on paralysed patients; however this would not distinguish between those who have been paraplegic for 25 years and newly paralysed patients. 6. National standards and guidelines

 Joint Standards Development Group, South of England Spinal Cord Injury Review Group
(2003) ‘Standards for Patients Requiring Spinal Cord Injury Care’ available from - www.mascip.co.uk (Note: under revision in 2008/09)  British Orthopaedic Association (2006) ‘The Initial Care and Transfer of Patients with Spinal Cord Injuries’ available from - www.sbns.org.uk  Royal College of Physicians (2008) ‘Chronic Spinal Cord Injury: Management of Patients in Acute Hospital Settings’ available from - www.rcplondon.ac.uk  See also Part II, Section 6 of this Definition SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009
Part II: Complex spinal surgery including spinal deformity surgery and reconstructive
spinal surgery
1. General description of complex spinal surgery including spinal deformity surgery and
reconstructive spinal surgery

This service encompasses aspects of care provided by spinal surgeons from both orthopaedic and
neurosurgery disciplines. Increasingly these complex cases are treated with close collaboration
between spinal surgeons from both disciplines. Some facets of this specialised service are
essentially the sole province of one or other of these disciplines - e.g. intra-dural lesions
(neurosurgery) or scoliosis (orthopaedic surgery). Spinal surgeons from both disciplines,
however, each undertake many of the procedures listed in Appendix 2. There are six areas of
complex spinal surgery:
 spinal deformity surgery
 spinal reconstruction surgery (trauma, tumour, infection);
 primary cervical, primary thoracic and primary anterior lumbar surgery
 revision surgery
 interventions for severe back pain
 palliative or curative spinal oncology surgery.
Specialised spinal services may be delivered by a single centre or, increasingly, by several
hospitals working in a collaborative network. Networks allow resources and expertise to be
shared, with common audit and governance arrangements, whereby complex surgery can be
delivered safely by several providers within the network.
2. Rationale for the service being included in the Specialised Services National Definition
Set
These services are not provided by local hospitals because the cases are uncommon, technically
demanding and require significant familiarity with the principles of complicated instrumentation
of the spine. It would be unusual for this expertise, and more importantly for the support services
required to manage these patients, to be available in small to medium sized local hospitals. The
expertise tends to be centred in large teaching hospitals or large orthopaedic, neurosurgical or
paediatric units.
3. Links to other services in the Specialised Services National Definition Set

Definition No.1, Specialised Cancer Services (adults)
Definition No.5, Assessment and Provision of Equipment for People with Physical Complex
Disabilities (all ages)
Definition No. 6, Specialised Spinal Services (all ages) - Part I: Spinal cord injuries of traumatic
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 non-progressive and non-traumatic non-progressive origin

Definition No.7, Complex Specialised Rehabilitation for Brain Injury and Complex Disability
(adults)
Definition No.8, Specialised Neurosciences Services (adult) - some complex spinal surgery will
be undertaken in neurosciences centres
Definition No.23, Specialised Services for Children - includes paediatric neurosciences, complex
disability, rehabilitation and neuropsychiatry
Definition No.31, Specialised Pain Management Services (adult)
Definition No.34, Specialised Orthopaedic Services (adult)
For spinal reconstruction services the links with other specialties depend upon the primary
pathology – e.g. strong links with the oncology services are required for reconstruction after
metastatic tumours; links with histopathology and control of infection services are required for
the osteomyelitis cases; and spinal cord injury rehabilitation services may be needed to care for
patients with established neurological injury once spinal reconstruction has been undertaken.
4. Detailed description of specialised complex spinal surgery activity
This will be considered in six groups.
4.1 Spinal deformity

Spinal deformity services deal predominantly with the effects of deformity of the spine in
children and adolescents. Demand for paediatric and adolescent services is likely to remain stable
but there is an increasing demand for services to adults who have either had untreated spinal
deformity, late complications of older forms of treatments or deformity arising from degenerative
changes. The co-morbidity in adult scoliosis patients requires specialist expertise.
It is suggested that all spinal procedures for conditions listed in paragraph 4.1 below would
additionally need OPCS code V55.2 (i.e. two levels of spinal) or V55.3 (i.e. greater than two
levels of spine) for the procedure to be deemed specialised. However it should be recognised that
there are exceptional circumstances in which a single level procedures would be regarded
specialised (e.g. spondyloptosis, excision of hemivertebra, post traumatic kyphosis and the
excision of single level tumours).
Structural scoliosis: This is an uncommon condition; idiopathic scoliosis affects girls to boys in
a ratio of 4 ½:1 and affects approximately 1.5 girls per thousand population. Only spinal
deformity of a significant magnitude requires treatment and is undertaken by corrective bracing
and casting or surgical intervention. A small number of children will have other conditions which
pre-dispose to scoliosis.
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 Other deformities: Kyphosis, vertebral anomalies and severe spondylolisthesis usually occur in
children and adolescents and are less common than idiopathic scoliosis. Some children will
require surgery at a very young age with implications for the support services required. Children
with congenital abnormalities will have a high risk of spontaneous spinal cord damage and will
need immediate assessment by a deformity surgeon after diagnosis.
Patient management: Patients are referred directly by GPs or, more often, as referrals from
other hospital consultants. Specialised radiological investigations will determine the nature of the
scoliosis and any associated abnormalities. If surgery is planned, then further specialised services
such as neurophysiology, anaesthesia, intensive care and allied medical specialities will be
involved. Children typically remain under the care of a spinal deformity service until spinal
maturity (at age of about 20) or until spinal stability has been achieved. Smaller children whose
spines are growing may require multiple operations over a period of time.
There are a number of complex conditions in which a spinal deformity is only part of the overall
pathology; for example: cerebral palsy, muchopolysaccharide disorders, Rett’s syndrome,
neuromuscular disease and other congenital abnormalities. Such patients will require specialist
paediatric management together with possible input from neurologists, urologists, geneticists,
geriatricians, respiratory physicians and others. Typically care will be required from birth and
will continue during and after spinal surgery. These requirements, along with provision of
paediatric anaesthesia and paediatric intensive care, will inform the choice of location of
specialised spinal services.
The use of devices to modify chest wall deformity related to spinal deformity (to reduce the
pulmonary restriction in very young children) is a recent development for evaluation in a few
specialist centres.
4.2 Spinal reconstruction
Tumours, infection and spinal fracture can threaten life and spinal cord function. Spinal
reconstruction for tumours and infection is always specialised; spinal reconstruction for fracture
is only specialised if associated with a SCI or thoracic or lumbar anterior procedure. Complex
spinal reconstruction will often involve a multidisciplinary approach and a number of procedures
aimed at restoration/maintenance of spinal cord function and reconstruction to restore/maintain
the structural or mechanical integrity of the spine. These may be staged over time and involve
approaches to the front and back of the spine. The underlying pathology of
tumour, trauma or infection requires a multidisciplinary approach with specialized support
facilities available.
Surgery is the usual treatment of choice with the aim of restoring the structural integrity of the
spine to allow the patient to regain mobility, to reverse or arrest neurological deficit and to
reduce or abolish pain.
The need for liaison with various specialities varies considerably depending on the underlying
cause: metastatic disease requires adjuvant therapy in the form of chemotherapy or radiotherapy
from oncologists and radiotherapists and the decision to offer surgery is often made in
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 conjunction with these other disciplines; treatment of infections requires input from infectious
disease and microbiology services; spinal trauma is usually the result of high energy injury and
patients will frequently have associated musculoskeletal injuries and/or multiple injuries
requiring major musculoskeletal injury and trauma services. The restoration of function after
spinal trauma without cord injury requires multidisciplinary input. Cord injured patients will
require the input of rehabilitation specialists in spinal injuries centres (see Part I – Spinal Cord
Injury).
Patients will need to be cared for over a variable period but multiple operations are unusual with
the exception of patients with multiple metastatic disease.
4.3 Primary cervical, primary thoracic, primary anterior lumbar surgery
Surgery on the cervical and thoracic spine, together with anterior approaches to the lumbar spine
are complex because of: potential hazards to the spinal cord, difficulties in approach, complexity
of instrumentation and its implantation and the use of spinal cord monitoring or “awake”
anaesthesia. One emerging technology is artificial disc replacement in the cervical and lumbar
spine, instead of the more traditional fusion. The number of patients suitable for pain relief
surgery is small and requires careful patient selection (see Section 4.5).

4.4 Revision surgery
Revision spinal surgery is more difficult because of the alteration of the anatomy, scarring and
adhesions. The risk of injury to neurological structures is significantly increased. The results of
revision surgery are well recognised to be significantly worse than those of primary surgery and
will need to be carried out by specialist spinal surgery units. Length of stay is longer than
primary surgery and with complications can be significantly extended.
4.5 Interventions for severe back pain
Generally management of lower back pain is not a specialised service; it is a very high volume
service and is undertaken in primary care and the local hospital, mainly by orthopaedic surgeons
but also by nurse specialists, physiotherapists and others. Improved provision of
multidisciplinary functional restoration programmes or pain management programmes reduces
the need for axial back pain surgery for chronic disability. Interventions for severe back pain
which are specialised include anterior spinal surgery and implanting indwelling epidural
catheters or dorsal column stimulators.

4.6 Palliative or curative spinal oncology surgery
5. Identifying and costing complex spinal surgery activity

5.1 Existing currencies
 out-patient attendances
 day cases / in-patients
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009  Spinal ICU bed days
 HRG codes.
5.2 Existing classification systems
 ICD codes (see Appendix)
Note the ICD10 diagnostic codes in the Appendix spreadsheet identify conditions related to
spinal surgery. Please note that both the specialist spinal surgery centre and the local hospital
may use some of these diagnostic codes and hence the codes cannot be used to specifically
identify specialised spinal surgery.
 OPCS intervention codes (see Appendix).
5.3 Costing activity
Please refer to the latest Department of Health Guidance on Payment by Results for up to date
information on national tariffs and activity included/excluded from tariff.
Please note that not all the Payment by Results inclusions and exclusions listed below are
specialised activity, but they are included here for completeness.
In scope of 2009/10 Payment by Results and has national tariffs:
 trauma and orthopaedics first/follow-up and single/multi-professional out-patients
attendances (Treatment Function Codes: 110 and 214)  day cases and in-patients
 various HRG codes.
(ii) Excluded from 2009/10 Payment by Results therefore local tariff to be negotiated:
 neurosurgery out-patient attendances (Treatment Functions Codes: 150 and 218)
 rehabilitation out-patient attendances (Treatment Function Code: 314)
 rehabilitation services
 balloon kyphoplasty
 sacral and spinal cord nerve stimulators
 high cost drugs
 critical care
 nationally commissioned services
 see also list of specific HRG exclusions.

5.4 Outstanding issues raised regarding currencies and classification systems

Cost of implants: the development of complex deformity surgery has seen a marked advance in
implants used and the recent trend of using pedicle screws at multiple levels has increased the
cost of implants. These are currently outside tariff.
One of the major problems with using clinical codes to identify spinal reconstruction activity is
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009 that spinal reconstruction is not easily codeable if it is not treating deformity. Major spinal
reconstruction for infection, trauma and tumour involves the same techniques and complexity as
deformity surgery but some of the most precise OPCS codes for major spinal instrumentation are
for deformity correction only (all the codes in V41). Major reconstruction may be aiming to
avoid deformity rather than correct it. Spinal instrumentation is widely used in major
reconstruction but OPCS classification fails to provide alternatives to using V41. Alternative
codes are likely to involve codes for fusion and “other operations on spine” that may not usually
be viewed as specialised.
6. National standards and guidelines

Available from National Institute for Health and Clinical Excellence - www.nice.org.uk

 NICE (2008) ‘Metastatic spinal cord compression: diagnosis and management of patients at
risk or of with metastatic spinal cord compression, NICD Clinical Guideline CG75’  NICE (2008) ‘Pain (chronic neuropathic or ischaemic) - spinal cord stimulation, NICE  NICE (tba) ‘The acute management of patients with chronic (longer than 6 weeks) non- specific low back pain, NICE Clinical Guideline’
Available from British Scoliosis Society - www.boa.ac.uk

 The British Scoliosis Society Executive (2003) ‘The management of spinal deformity in the

Endorsements

Definition No. 6 Specialised Spinal Services (all ages) has been endorsed by
British Association of Spinal Surgeons
British Scoliosis Society.
SSNDS Definition No. 6 Specialised Spinal Services (all ages) Third edition 2009
Stanmore (Royal National Orthopaedic Hospital NHS Trust)
Royal National Orthopaedic Hospital
Brockley Hill
Stanmore
Middlesex HA7 4LP
Salisbury (Salisbury NHS Foundation Trust)
The Duke of Cornwall Spinal Treatment Centre
Salisbury District Hospital
Salisbury
Wiltshire SP2 8BJ
Stoke Mandeville (Buckinghamshire Hospitals NHS Trust)
National Spinal Injuries Centre
Stoke Mandeville Hospital
Mandeville Road
Aylesbury
Buckinghamshire HP21 8AL
Sheffield (Sheffield Teaching Hospitals NHS Foundation Trust)
The Princess Royal Spinal Injuries Unit
Osborn Building
Northern General Hospital
Herries Road
Sheffield S5 7AU
Wakefield (The Mid Yorkshire Hospitals NHS Trust)
The Yorkshire Regional Spinal Injuries Centre
Pinderfields General Hospital
Aberford Road
Wakefield
West Yorkshire WF1 4DG
Southport (Southport & Ormskirk Hospital NHS Trust)
Regional Spinal Injuries Centre
Southport and Formby District General Hospital
Town Lane
Kew
Southport
Merseyside PR8 6PN
Middlesbrough (South Tees Hospitals NHS Trust)
The Golden Jubilee Regional Spinal Injuries Centre
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW
Oswestry (the Robert Jones & Agnes Hunt Orthopaedic & District Hospital NHS Trust)
The Midland Centre for Spinal Injuries (MCSI)
Robert Jones & Agnes Hunt Orthopaedic & District Hospital
Oswestry
Shropshire SY10 7AG
ICD codes for Definition 6. Specialised Spinal Services (all ages) 3rd edition
Note: the ICD10 diagnostic codes in the Appendix spreadsheet identify conditions related to spinal surgery. Please note that both the specialist spinal surgery centre and the local hospital may use some of these diagnostic codes and hence the codes cannot be used to specifically identify specialised spinal surgery.
ICD10
CODE ICD10 CATEGORY
ICD10 SUB-CATEGORY
Malignant neoplasm of spinal cord cranial nerves and other parts of central nervous system Malignant neoplasm of spinal cord, cranial nerves and other parts of central nervous system Malignant neoplasm of spinal cord, cranial nerves and other parts of central nervous system Malignant neoplasm, overlapping lesion of brain and other parts of central nervous system G060 Intracranial and intraspinal abscess and granuloma G061 Intracranial and intraspinal abscess and granuloma G062 Intracranial and intraspinal abscess and granuloma Extradural and subdural abscess, unspecified G07X Intracranial and intraspinal abscess and granuloma in diseases classified eleswhere Intracranial and intraspinal abscess and granuloma in diseases classified elsewhere G08X Intracranial and intraspinal phlebitis and thrombophlebitis Intracranial and intraspinal phlebitis and thrombophlebitis G120 Spinal muscular atrophy and related syndromes Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] G121 Spinal muscular atrophy and related syndromes G122 Spinal muscular atrophy and related syndromes G128 Spinal muscular atrophy and related syndromes Other spinal muscular atrophies and related syndromes G129 Spinal muscular atrophy and related syndromes G130 Systemic atrophies primarily affecting central nervous system in diseases classified eleswhere Paraneopastic neuromyopathy and neuropathy G131 Systemic atrophies primarily affecting central nervous system in diseases classified eleswhere Other systemic atrophy primarily affecting central nervous system in neoplastic diseases G132 Systemic atrophies primarily affecting central nervous system in diseases classified eleswhere Systemic atrophy primarily affecting central nervous system in myxoedema G138 Systemic atrophies primarily affecting central nervous system in diseases classified eleswhere Systemic atrophy primarily affecting central nervous system in other diseases classified elsewhere G961 Other disorders of central nervous system Disorders of meninges, not elsewhere classified G98X Other disorders of nervous system, not elsewhere classified Other disorders of nervous system, not elsewhere classified G992 Other disorders of nervous system in diseases classified elsewhere Myelopathy in diseases classified elsewhere G998 Other disorders of nervous system in diseases classified elsewhere Other specified disorders of nervous system in diseases classified elsewhere Staphylococcal arthritis and polyarthritis Other streptococcal arthritis and polyarthritis Arthritis and polyarthritis due other specified bacterial agents Recurrent atlantoaxial subluxation with myelopathy Infection of intervertebral disc (pyogenic) Other specified inflammatory spondylopathies Anterior spinal and vertebral artery compression syndromes Collapsed vertebra, not elsewhere classified M490 Spondylopathies in diseases classified elsewhere M491 Spondylopathies in diseases classified elsewhere M492 Spondylopathies in diseases classified elsewhere M493 Spondylopathies in diseases classified elsewhere Spondylopathy in other infectious and parasitic diseases classified elsewhere M494 Spondylopathies in diseases classified elsewhere M495 Spondylopathies in diseases classified elsewhere Collapsed vertebra in diseases classified elsewhere M498 Spondylopathies in diseases classified elsewhere Spondylopathy in other diseases classified elsewhere M532 Other dorsopathies, not elsewhere classified Q762 Congenital malformations of spine and bony thorax Q763 Congenital malformations of spine and bony thorax Congenital scoliosis due to congenital bony malformation Q764 Congenital malformations of spine and bony thorax Other congenital malformations of spine not associated with scoliosis Q766 Congenital malformations of spine and bony thorax Q768 Congenital malformations of spine and bony thorax Other congenital malformations of bony thorax Q769 Congenital malformations of spine and bony thorax Congenital malformation of bony thorax, unspecified Q770 Osteochondrodysplasia with defects of growth of tubular bones andspine Q771 Osteochondrodysplasia with defects of growth of tubular bones andspine Q772 Osteochondrodysplasia with defects of growth of tubular bones andspine Q773 Osteochondrodysplasia with defects of growth of tubular bones andspine Q774 Osteochondrodysplasia with defects of growth of tubular bones andspine Q775 Osteochondrodysplasia with defects of growth of tubular bones andspine Q776 Osteochondrodysplasia with defects of growth of tubular bones andspine Q777 Osteochondrodysplasia with defects of growth of tubular bones andspine Q778 Osteochondrodysplasia with defects of growth of tubular bones andspine Other osteochondrodysplas with defects growth of tubular bones and spine Q779 Osteochondrodysplasia with defects of growth of tubular bones andspine Osteochondrodysplasia with defects growth tubular bones and spine, unspecified Other specified other osteochondrodysplasias Multiple fractures of lumbar spine and pelvis Fracture of other and unspecified parts of lumbar spine and pelvis Disloclocation, sprain and strain of joints and ligaments of lumbar spine and pelvis Traumatic rupture of lumbar intervertebral disc Disloclocation, sprain and strain of joints and ligaments of lumbar spine and pelvis Disloclocation, sprain and strain of joints and ligaments of lumbar spine and pelvis Dislocation of sacroiliac and sacrococcygeal joint Disloclocation, sprain and strain of joints and ligaments of lumbar spine and pelvis Dislocation of other and unspecified parts of lumbar spine and pelvis Injury of nerves and lumbar spinal cord at abdomen, low back and pelvis level Concussion and oedema of lumbar spinal cord Injury of nerves and lumbar spinal cord at abdomen, low back and pelvis level Injury of nerves and lumbar spinal cord at abdomen, low back and pelvis level Injury of nerve root of lumbar and sacral spine Injury of nerves and lumbar spinal cord at abdomen, low back and pelvis level Injury of nerves and lumbar spinal cord at abdomen, low back and pelvis level Injury of nerves and lumbar spinal cord at abdomen, low back and pelvis level Injury of lumbar, sacral and pelvic sympathetic nerves OPCS codes for Definition 6. Specialised Spinal Services (all ages) 3rd edition
OPCS
CODE OPCS CATEGORY
OPCS SUB-CATEGORY
ised
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Excision of lesion of intramedullary spinal cord Excision of lesion of extradural spinal cord Other specified partial extirpation of spinal cord Unspecified partial extirpation of spinal cord A45.1 Other open operations on spinal cord A45.2 Other open operations on spinal cord A45.3 Other open operations on spinal cord A45.4 Other open operations on spinal cord Open biopsy of lesion of spinal cord Includes: Open biopsy of spinal cord A45.5 Other open operations on spinal cord A45.6 Other open operations on spinal cord A45.8 Other open operations on spinal cord Other specified other open operations on spinal cord A45.9 Other open operations on spinal cord Unspecified other open operations on spinal cord Needle destruction of substania gelatinosa of cervical spinal cord Radiofrequency controlled thermal destruction of spinothalamic tract Other specified other destruction of spinal cord Unspecified other destruction of spinal cord Biopsy of lesion of spinal cord NEC Includes: Biopsy of spinal cord NEC Insertion of neurostimulator adjacent to spinal cord Attention to neurostimulator adjacent to spinal cord NEC Reprogramming of neurostimulator adjacent to spinal cord Removal of neurostimulator adjacent to spinal cord Insertion of neurostimulator electrodes into the spinal cord Other specified other operations on spinal cord Unspecified other operations on spinal cord Freeing of spinal tether NEC Includes: Division of tethered filum terminale Complex freeing of spinal tether Includes: Complex reduction of abnormal tissue to free spinal cord A51.1 Other operations on meninges of spinal cord Extirpation of lesion of meninges of spinal cord A51.2 Other operations on meninges of spinal cord Freeing of adhesions of meninges of spinal cord A51.3 Other operations on meninges of spinal cord Biopsy of lesion of meninges of spinal cord Includes: Biopsy of meninges of spinal cord A51.8 Other operations on meninges of spinal cord Other specified other operations on meninges of spinal cord A51.9 Other operations on meninges of spinal cord Unspecified other operations on meninges of spinal cord coding could be lumbar puncture ? Lumbar puncture Injection of destructive substance into cerebrospinal fluid Implantation of intrathecal drug delivery device adjacent to spinal cord Attention to intrathecal drug delivery device adjacent to spinal cord Removal of intrathecal drug delivery device adjacent to spinal cord Other specified therapeutic spinal puncture Extirpation of lesion of spinal nerve root Reimplantation of spinal nerves into spinal cord V22.1 Primary decompression operations on cervical spine Primary anterior decompression of cervical spinal cord and fusion of joint of cervical spine sometimes done by trained ortho spine in DGH V22.2 Primary decompression operations on cervical spine Primary anterior decompression of cervical spinal cord NEC sometimes done by trained ortho spine in DGH V22.3 Primary decompression operations on cervical spine V22.4 Primary decompression operations on cervical spine Primary anterior corpectomy of cervical spine with reconstruction HFQ V22.5 Primary decompression operations on cervical spine Primary decompression of posterior fossa and upper cervical spinal cord and instrumentation V22.6 Primary decompression operations on cervical spine Primary decompression of posterior fossa and upper cervical spinal cord NEC V22.8 Primary decompression operations on cervical spine Other specified primary decompression operations on cervical spine V22.9 Primary decompression operations on cervical spine Unspecified primary decompression operations on cervical spine V23.1 Revisional decomprssion operations on cervical spine Revisional anterior decompression of cervical spinal cord and fusion of joint of cervical spine V23.2 Revisional decomprssion operations on cervical spine Revisional anterior decompression of cervical spinal cord NEC V23.3 Revisional decomprssion operations on cervical spine Revisional foraminotomy of cervical spine V23.4 Revisional decomprssion operations on cervical spine Revisional anterior corpectomy of cervical spine with reconstruction HFQ V23.5 Revisional decomprssion operations on cervical spine Revisional decompression of posterior fossa and upper cervical spinal cord and instrumentation V23.6 Revisional decomprssion operations on cervical spine Revisional decompression of posterior fossa and upper cervical spinal cord NEC V23.8 Revisional decomprssion operations on cervical spine Other specified revisional decompression operations on cervical spine V23.9 Revisional decomprssion operations on cervical spine Unspecified revisional decompression operations on cervical spine V24.1 Decompression operations on thoracic spine Primary decompression of thoracic spinal cord and fusion of joint of thoracic spine posterior approach - depends on approach & pathology V24.2 Decompression operations on thoracic spine Primary decompression of thoracic spinal cord NEC posterior approach - depends on approach & pathology V24.3 Decompression operations on thoracic spine Revisional decompression of thoracic spinal cord NEC V24.4 Decompression operations on thoracic spine Primary anterior corpectomyof thoracic spine and reconstruction HFQ V24.5 Decompression operations on thoracic spine Revisional anterior corpectomy of thoracic spine and reconstruction HFQ V24.8 Decompression operations on thoracic spine Other specified decompression operations on thoracic spine V24.9 Decompression operations on thoracic spine Unspecified decompression operations on thoracic spine V25.7 Primary decompression operations on lumbar spine Primary anterior corpectomy of lumbar spine and reconstruction V26.1 Revisional decompression operations on lumber spine Revisional extended decompression of lumbar spinal cord and intertranverse fusion of joint of lumbar spine V26.2 Revisional decompression operations on lumber spine Revisional extended decompression of lumbar spinal cord NEC V26.3 Revisional decompression operations on lumber spine Revisional posterior decompression of lumbar spinal cord and intertranverse fusion of joint of lumbar spine V26.4 Revisional decompression operations on lumber spine Revisional posterior laminectomy decompression of lumbar spinal cord V26.5 Revisional decompression operations on lumber spine Revisional posterior decompression of lumbar spinal cord NEC V26.6 Revisional decompression operations on lumber spine Revisional lateral foraminotomy of lumbar spine V26.7 Revisional decompression operations on lumber spine Revisional anterior corpectomy of lumbar spine and reonstruction HFQ V26.8 Revisional decompression operations on lumber spine Other specified revisional decompression operations on lumbar spine V26.9 Revisional decompression operations on lumber spine Unspecified revisional decompression operations on lumbar spine V27.1 Decompression operations on unspecified spine Primary decompression of spinal cord and fusion of joint of spine NEC V27.3 Decompression operations on unspecified spine Revisional decompression of spinal cord NEC V27.8 Decompression operations on unspecified spine Other specified decompression operations on unspecified spine V27.9 Decompression operations on unspecified spine Unspecified decompression operations on unspecified spine V28.8 Insertion of lumbar interspinous process spacer Other specified insertion of lumbar interspinous process spacer V28.9 Insertion of lumbar interspinous process spacer Unspecified insertion of lumbar interspinous process spacer V29.1 Primary excision of cervical intervertebral disc Primary laminectomy excision of cervical intervertebral disc V29.2 Primary excision of cervical intervertebral disc Primary hemilaminectomy excision of cervical intervertebral disc V29.3 Primary excision of cervical intervertebral disc Primary fenestration excision of cervical intervertebral disc V29.6 Primary excision of cervical intervertebral disc Primary microdiscectomy of cervical intervertebral disc V29.8 Primary excision of cervical intervertebral disc Other specified primary excision of cervical intervertebral disc V29.9 Primary excision of cervical intervertebral disc Unspecified primary excision of cervical intervertebral disc V30.1 Revisional excision of cervical intervertebral disc Revisional laminectomy excision of cervical intervertebral disc V30.2 Revisional excision of cervical intervertebral disc Revisional hemilaminectomy excision of cervical intervertebral disc V30.3 Revisional excision of cervical intervertebral disc Revisional fenestration excision of cervical intervertebral disc V30.4 Revisional excision of cervical intervertebral disc Revisional anterior excision of cervical intervertebral disc and interbody fusion of joint of cervical spine V30.5 Revisional excision of cervical intervertebral disc Revisional anterior excision of cervical intervertebral disc NEC V30.6 Revisional excision of cervical intervertebral disc Revisional microdisectomy of cervical intervertebral disc V30.8 Revisional excision of cervical intervertebral disc Other specified revisional excision of cervical intervertebral disc V30.9 Revisional excision of cervical intervertebral disc Unspecified revisional excision of cervical intervertebral disc V31.1 Primary excision of thoracic intervertebral disc Primary anterolateral excision of thoracic intervertebral disc and graft HFQ V31.2 Primary excision of thoracic intervertebral disc Primary anterolateral excision of thoracic intervertebral disc NEC V31.3 Primary excision of thoracic intervertebral disc Primary costotransversectomy of thoracic intervertebral disc V31.4 Primary excision of thoracic intervertebral disc Primary percutaneous endoscopic excision of thoracic intervertebral disc V31.8 Primary excision of thoracic intervertebral disc Other specified primary excision of thoracic intervertebral disc V31.9 Primary excision of thoracic intervertebral disc Unspecified primary excision of thoracic intervertebral disc V32.1 Revisional excision of thoracic intervertebral disc Revisional anterolateral excision of thoracic intervertebral disc and graft HFQ V32.2 Revisional excision of thoracic intervertebral disc Revisional anterolateral excision of thoracic intervertebral disc NEC V32.3 Revisional excision of thoracic intervertebral disc Revisional costotransversectomy of thoracic intervertebral disc V32.4 Revisional excision of thoracic intervertebral disc Revisional percutaneous endoscopic excision of thoracic intervertebral disc V32.8 Revisional excision of thoracic intervertebral disc Other specified revisional excision of thoracic intervertebral disc V32.9 Revisional excision of thoracic intervertebral disc Unspecified revisional excision of thoracic intervertebral disc V33.3 Primary excision of lumbar intervertebral disc Primary anterior excision of lumbar intervertebral disc and interbody fusion of joint of lumbar spine V33.4 Primary excision of lumbar intervertebral disc Primary anterior excision of lumbar intervertebral disc NEC V33.5 Primary excision of lumbar intervertebral disc Primary anterior excision of lumbar intervertebral disc and posterior graft fusion of joint of lumbar spine V33.6 Primary excision of lumbar intervertebral disc Primary anterior excision of lumbar intervertebral disc and posterior instrumentation of lumbar spine V34.1 Revisional excision of lumbar intervertebral disc Revisional laminectomy excision of lumbar intervertebral disc V34.2 Revisional excision of lumbar intervertebral disc Revisional fenestration excision of lumbar intervertebral disc V34.3 Revisional excision of lumbar intervertebral disc Revisional anterior excision of lumbar intervertebral disc and interbody fusion of joint of lumbar spine V34.4 Revisional excision of lumbar intervertebral disc Revisional anterior excision of lumbar intervertebral disc NEC V34.5 Revisional excision of lumbar intervertebral disc Revisional anterior excision of lumbar intervertebral disc and posterior graft fusion of joint of lumbar spine V34.6 Revisional excision of lumbar intervertebral disc Revisional anterior excision of lumbar intervertebral disc and posterior instrumentation of lumbar spine V34.7 Revisional excision of lumbar intervertebral disc Revisional microdiscectomy of lumbar intervertebral disc V34.8 Revisional excision of lumbar intervertebral disc Other specified revisional excision of lumbar intervertebral disc V34.9 Revisional excision of lumbar intervertebral disc Unspecified revisional excision of lumbar intervertebral disc V36.1 Prosthetic replacement of intervertebral disc Prosthetic replacement of cervical intervertebral disc V36.2 Prosthetic replacement of intervertebral disc Prosthetic replacement of thoracic intervertebral disc V36.3 Prosthetic replacement of intervertebral disc Prosthetic replacement of lumbar intervertebral disc V36.8 Prosthetic replacement of intervertebral disc Other specified prosthetic replacement of intervertebral disc V36.9 Prosthetic replacement of intervertebral disc Unspecified prosthetic replacement of intervertebral disc V37.1 Primary fusion of joint of cervical spine V37.3 Primary fusion of joint of cervical spine V37.4 Primary fusion of joint of cervical spine V37.8 Primary fusion of joint of cervical spine Other specified primary fusion of joint of cervical spine V37.9 Primary fusion of joint of cervical spine Unspecified primary fusion of joint of cervical spine V38.6 Primary fusion of other joint of cervical spine Primary transforaminal interbody fusion of joint of lumbar spine V39.3 revisional fusion of joint of spine Revisional posterior interlaminar fusion of joint of lumbar spine grafting of pseudarthrosis not a specialist procedure V39.4 revisional fusion of joint of spine Revisional posterior fusion of joint of lumbar spine NEC grafting of pseudarthrosis not a specialist procedure V39.5 revisional fusion of joint of spine Revisional intertransverse fusion of joint of lumbar spine NEC grafting of pseudarthrosis not a specialist procedure V39.6 revisional fusion of joint of spine Revisional posterior interbody fusion of joint of lumbar spine grafting of pseudarthrosis not a specialist procedure V39.7 revisional fusion of joint of spine Revisional transforaminal interbody fusion of joint of lumbar spine grafting of pseudarthrosis not a specialist procedure V39.8 revisional fusion of joint of spine Other specified revisional fusion of joint of spine V39.9 revisional fusion of joint of spine Unspecified revsional fusion of joint of spine always specialised for scoliosis, tumour and fracture , V41.1 Instrumental correction of deformity of spine Posterior attachment of correctional instrument to spine but some code to this for adult degenerative scoliosisalways specialised for scoliosis, tumour and fracture , V41.2 Instrumental correction of deformity of spine Anterior attachment of correctional instrument to spine but some code to this for adult degenerative scoliosis V41.3 Instrumental correction of deformity of spine Removal of correctional instrument from spine V41.8 Instrumental correction of deformity of spine Other specified instrumental correction of deformity of spine V41.9 Instrumental correction of deformity of spine Unspecified instrumental correction of deformity of spine V421 Other correction of deformity of spine V42.2 Other correction of deformity of spine Epiphysiodesis of spinal apophyseal joint for correction of deformity V42.3 Other correction of deformity of spine Anterolateral release of spine for correction of deformity and graft HFQ V42.4 Other correction of deformity of spine Anterior and posterior epiphysiodesis of spine for correction of deformity V42.5 Other correction of deformity of spine Anterior epiphysiodesis of spine for correction of deformity NEC V42.6 Other correction of deformity of spine Posterior epiphysiodesis of spine for correction of deformity NEC V42.8 Other correction of deformity of spine Other specified other correction of deformity of spine V42.9 Other correction of deformity of spine Unspecified other correction of deformity of spine Complex decompression of fracture of spine Anterior decompression of fracture of spine Posterior decompression of fracture of spine NEC Other specified decompression of fracture of spine Unspecified decompression of fracture of spine V45.1 Other reduction of fracture of spine Open reduction of fracture of spine and excision of facet of spine V45.2 Other reduction of fracture of spine Fixation of fracture of spine using plate Fixation of fracture of spine using Harrington rod Transoral excision of odontoid process of axis See section 4.1 in complex spinal surgery See section 4.1 in complex spinal surgery See section 4.1 in complex spinal surgery See section 4.1 in complex spinal surgery See section 4.1 in complex spinal surgery Primary laser foraminoplasty of cervical spine Primary laser foraminoplasty of thoracic spine Primary laser foraminoplasty of lumbar spine Primary laser foraminoplasty of spine nec Other specified primary foraminoplasty of spine Unspecified primary foraminoplasty of spine V57.1 Revisional formaminoplasty of spine Revisional laser foraminoplasty of cervical spine V57.2 Revisional formaminoplasty of spine Revisional laser foraminoplasty of thoracic spine V57.3 Revisional formaminoplasty of spine Revisional laser foraminoplasty of lumbar spine V57.4 Revisional formaminoplasty of spine Revisional laser foraminoplasty of spine NEC V57.8 Revisional formaminoplasty of spine Other specified revisional foraminoplasty V57.9 Revisional formaminoplasty of spine V58.1 Primary automated percutaneous mechanical excision of intervertebral disc Primary automated percutaneous mechanical excision of cervical intervertebral disc V58.2 Primary automated percutaneous mechanical excision of intervertebral disc Primary automated percutaneous mechanical excision of thoracic intervertebral disc V58.3 Primary automated percutaneous mechanical excision of intervertebral disc Primary automated percutaneous mechanical excision of lumbar intervertebral disc V58.8 Primary automated percutaneous mechanical excision of intervertebral disc Other specified primary automated percutaneous mechanical excision of intervertebral disc V58.9 Primary automated percutaneous mechanical excision of intervertebral disc Unspecified primary automated percutaneous mechanical excision of intervertebral disc V59.1 Revisional automated percutaneous mechanical excision of intervertebral disc Revisional automated percutaneous mechanical excision of cervical intervertebral disc V59.2 Revisional automated percutaneous mechanical excision of intervertebral disc Revisional automated percutaneous mechanical excision of thoracic intervertebral disc V59.3 Revisional automated percutaneous mechanical excision of intervertebral disc Revisional automated percutaneous mechanical excision of lumbar intervertebral disc V59.8 Revisional automated percutaneous mechanical excision of intervertebral disc Other specified revisional automated percutaneous mechanical excision of intervertebral disc V59.9 Revisional automated percutaneous mechanical excision of intervertebral disc Unspecified revisional automated percutaneous mechanical excision of intervertebral disc V60.1 Primary percutaneous decompression using coblation to intervertebral disc Primary percutaneous decompression using coblation to cervical intervertebral disc V60.2 Primary percutaneous decompression using coblation to intervertebral disc Primary percutaneous decompression using coblation to thoracic intervertebral disc V60.3 Primary percutaneous decompression using coblation to intervertebral disc Primary percutaneous decompression using coblation to lumbar intervertebral disc V60.8 Primary percutaneous decompression using coblation to intervertebral disc Other specified primary percutaneous decompression using coblation to intervertebral disc V60.9 Primary percutaneous decompression using coblation to intervertebral disc Unspecified primary percutaneous decompression using coblation to intervertebral disc V61.1 Revisional percutaneous decompression using coblation to intervertebral disc Revisional percutaneous decompression using coblation to cervical intervertebral disc V61.2 Revisional percutaneous decompression using coblation to intervertebral disc Revisional percutaneous decompression using coblation to thoracic intervertebral disc V61.3 Revisional percutaneous decompression using coblation to intervertebral disc Revisional percutaneous decompression using coblation to lumbar intervertebral disc V61.8 Revisional percutaneous decompression using coblation to intervertebral disc Other specified revisional percutaneous decompression using coblation to intervertebral disc V61.9 Revisional percutaneous decompression using coblation to intervertebral disc Unspecified revisional percutaneous decompression using coblation to intervertebral disc V62.1 Primary percutaneous intrasdiscal radiofrequency theromcogulation to intervertebral disc Primary percutaneous intradiscal radiofrequency thermocoagulation to cervical intervertebral disc V62.2 Primary percutaneous intrasdiscal radiofrequency theromcogulation to intervertebral disc Primary percutaneous intradiscal radiofrequency thermocoagulation to thoracic intervertebral disc V62.3 Primary percutaneous intrasdiscal radiofrequency theromcogulation to intervertebral disc Primary percutaneous intradiscal radiofrequency thermocoagulation to lumbar intervertebral disc V62.8 Primary percutaneous intrasdiscal radiofrequency theromcogulation to intervertebral disc Other specified primary percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc V62.9 Primary percutaneous intrasdiscal radiofrequency theromcogulation to intervertebral disc Unspecified primary percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc V63.1 Revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc Revisional percutaneous intradiscal radiofrequency thermocoagulation to cervical intervertebral disc V63.2 Revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc Revisional percutaneous intradiscal radiofrequency thermocoagulation to thoracic intervertebral disc V63.3 Revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc Revisional percutaneous intradiscal radiofrequency thermocoagulation to lumbar intervertebral disc V63.8 Revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc Other specified revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc V63.9 Revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc Unspecified revisional percutaneous intradiscal radiofrequency thermocoagulation to intervertebral disc Curettage of lesion of bone and graft HFQ Curettage of tumour of bone and graft HFQ Other specified extirpation of lesion of bone Unspecified extirpation of lesion of bone

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