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Operative Flash Dictation Neurosurgery Handbook PDF
Operative Flash Dictation Neurosurgery Handbook PDF
NEUROSURGERY
Chaim B. Colen, M.D., Ph.D.
COPYRIGHT © 2008
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Operative Dictation: Neurosurgery
COPYRIGHT © 2008 by Colen Publishing, LLC. This book, including all parts
thereof, is legally protected by copyright. Any use, exploitation, or
commercialization outside the narrow limits set by copyright legislation without
the author’s consent is illegal and liable to prosecution. This applies in particular
to photostat reproduction, copying, mimeographing or duplication of any kind,
translating, preparation of microfilms and electronic data processing and
storage.
Some of the product names, patents and registered designs referred to in this
book are in fact registered trademarks or proprietary names even though
specific reference to this fact is not always made in the text. Therefore, the
appearance of a name without designation as proprietary is not to be construed
as a representation by the publisher that it is in the public domain.
Colen Publishing
“Infinite possibilities to
learning…”
www.colenpublishing.com
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Operative Dictation: Neurosurgery
CONTENTS
Table of Contents
CONTENTS ............................................................................................... iii
CONTRIBUTORS ....................................................................................... vi
DEDICATION ........................................................................................... vii
PREFACE ................................................................................................ viii
FORWARD ............................................................................................... ix
OPERATIVE INSTRUMENTS ....................................................................... 1
PERFORATOR DRILL BITS/ BURRS ...................................................... 2
DURAL SEPARATORS .......................................................................... 2
HOOKS ................................................................................................ 3
HOOKS ................................................................................................ 3
DISSECTORS ........................................................................................ 4
KERRISSON RONGEUR ....................................................................... 4
SCISSORS ............................................................................................ 4
SCISSORS/ CLAMPS/ FORCEPS ........................................................... 5
ELEVATORS ......................................................................................... 6
ELEVATORS ......................................................................................... 6
ELEVATORS ......................................................................................... 7
SUCTION TIPS ..................................................................................... 7
FORCEPS ............................................................................................. 8
BAYONET FORCEPS ............................................................................ 8
BAYONET FORCEPS ............................................................................ 9
MICRO SCISSORS ................................................................................ 9
MICRO SCISSORS .............................................................................. 10
BIPOLAR BAYONET FORCEPS ........................................................... 10
SPECULUMS ..................................................................................... 11
RETRACTORS .................................................................................... 11
NERVE ROOT RETRACTORS .............................................................. 12
CRANIAL PROCEDURES ........................................................................... 14
C RANIAL D ICTATIONS G UIDE ...................................................................... 15
BURR H OLE D RAINAGE FOR ....................................................................... 17
C HRONIC S UBDURAL H EMATOMA (SDH) E VACUATION ................................ 17
C RANIOTOMY FOR ..................................................................................... 20
A CUTE S UBDURAL H EMATOMA (SDH) E VACUATION .................................... 20
C RANIOTOMY FOR .................................................................................... 23
A CUTE E PIDURAL H EMATOMA (EDH) E VACUATION ..................................... 23
D ECOMPRESSIVE C RANIECTOMY FOR .......................................................... 26
I NTRACRANIAL H EMORRHAGE /STROKE / T RAUMATIC BRAIN I NJURY ............... 26
C RANIOPLASTY ......................................................................................... 30
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P ERCUTANEOUS DISCECTOMY .................................................................. 210
P OSTERIOR L UMBAR I NTERBODY F USION .................................................. 213
REDO I NSTRUMENTATION REMOVAL ......................................................... 218
T HORACIC C ORPECTOMY : L ATERAL E XTRACAVITARY A PPROACH .................. 224
T HORACIC C ORPECTOMY : T RANSTHORACIC A PPROACH .............................. 231
X‐STOP .................................................................................................. 236
VASCULAR/ENDOVASCULAR ................................................................. 239
PROCEDURES ....................................................................................... 239
C AROTID E NDARTERECTOMY .................................................................... 240
C EREBRAL A NGIOGRAPHY ........................................................................ 244
C EREBRAL A NGIOGRAM WITH A NEURYSM C OILING .................................... 248
C EREBRAL A NGIOGRAM WITH STENT ‐ ASSISTED A NEURYSM C OILING ............ 254
C EREBRAL A NGIOGRAM WITH A RTERIO ‐VENOUS M ALFORMATION (AVM)
E MBOLIZATION ....................................................................................... 260
A NGIOGRAM WITH C AROTID BALLOON A NGIOPLASTY AND S TENT P LACEMENT
............................................................................................................. 266
MINOR PROCEDURES ........................................................................... 272
A RTERIAL L INE P LACEMENT ..................................................................... 273
L UMBAR SPINAL P UNCTURE ..................................................................... 275
L UMBAR D RAIN P LACEMENT .................................................................... 278
VENTRICULOSTOMY P LACEMENT .............................................................. 281
VERTEBROPLASTY /K YPHOPLASTY .............................................................. 284
APPENDIX ............................................................................................ 288
ABBREVIATIONS ................................................................................... 289
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Operative Dictation: Neurosurgery
CONTRIBUTORS
FACULTY REVIEWERS
Alan Scarrow, M.D., J.D.
St. John's Clinic - Neurosurgery
1965 S. Fremont Ste. 130
Springfield, MO 65804
Gregory Przybylski, M.D.
Director of Neurosurgery
New Jersey Neuroscience Institute
JFK Medical Center, Edison, New Jersey
RESIDENTS
Raul Olivera, M.D.
Division of Neurosurgery
Department of Surgery
Saint Louis University School of Medicine
St. Louis, MO 63110
Christopher E. Lai
Wayne State University
Detroit, MI
Adam Robin
Wayne State University
Detroit, MI
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Operative Dictation: Neurosurgery
DEDICATION
My Motto: If you love yourself, you will love your patient and your patient will
love you. Live, Love and leave a Legacy.
Chaim Benjoseph Colen M.D., Ph.D. 09/03/02
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Operative Dictation: Neurosurgery
PREFACE
Concern for man and his fate must always form the chief
interest of all technical endeavors… Never forget this in the
midst of your diagrams and equations.
Albert Einstein
Operative dictations are an essential part of the neurosurgical
career. Excellent operative dictations can be likened to "Fidelio" the
beautiful Beethoven masterpiece. Each word must flow on a
musical note; translating 3‐dimensional neuroanatomic melodies
into a verbalized anatomic clinico‐surgical masterpiece. On the
other hand, a poor operative dictation can be perceived as the lack
of clinico‐scientific knowledge or poor comprehension of the
operation that was just performed.
In no way is this book comprehensive enough to cover all operative
dictations performed in neurosurgery; rather it is meant to be a
basic guide to allow the novice surgeon the scaffolding needed to
dictate a basic straight forward case. The most common cases are
described in a consistent format, with bolded statements meant to
reinforce the most important segments from the medico‐legal
standpoint. There are many times during our operative careers that
we deviate from the norm; this uniqueness should be dictated on a
per‐case‐basis. May this book benefit all residents and junior staff,
with the ultimate goal of improving our verbalized legacy of
Neurosurgery.
Chaim B. Colen
2008
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Operative Dictation: Neurosurgery
FORWARD
Most of us went into neurosurgery because we had a passion for
clinical tasks of our profession – listening to patients, thinking
about how to help them, performing the surgery, and finding out if
our efforts have helped them. I am confident very few of us have a
similar passion for the dictation, documentation, and paperwork
that necessarily accompany those more pleasant clinical tasks.
Nonetheless accurately recording what we do in our clinical and
surgical work is not just a good medico‐legal practice, it’s simply
good medicine.
In this book, Dr. Colen has made the task of documenting our
surgical work much easier. What follows are detailed operative
notes and CPT coding for the typical surgical work we do involving
spine, tumor, vascular, functional, and stereotactic procedures.
This will allow readers to take these templates, modify them to
their own unique variations for an individual procedure, and
incorporate them into the patient’s medical record. This should be
particularly helpful to those who are new to the responsibilities of
medical and surgical documentation.
In publishing this work, Dr. Colen is helping us as neurosurgeons
spend more time doing the things we love, and less time recording
how we did them. It is an admirable ambition.
Alan M. Scarrow, M.D., J.D.
Chairman, Section of Neurosurgery
St. John’s Clinic
Springfield, Missouri
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OPERATIVE INSTRUMENTS
L'OPÉRATION DU TRÉPAN
Trepanation is one of the earliest cranial operations performed
by man. It was carried out for both medical reasons and
mystical practices for a long time:
evidence of trepanation has
been found in prehistoric human remains from Neolithic times
onwards. The above artwork is from an 18th century French
illustration of trepanation. People believed the practice would
cure epileptic seizures, migraines, and mental disorders. In
prehistoric times, trepanation was thought to cure diseases by
letting evil spirits escape. The bone that was trepanned was
kept by the prehistoric people and worn as charms to keep evil
spirits away.
Encyclopédie Ou Dictionnaire Raisonné Des Sciences, Des Arts Et Des Métiers, 1772
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Operative Dictation: Neurosurgery
HOOKS
1 2 3 4 5 6 7
HOOKS
1 2 3 4 5 6 7
DISSECTORS
1 2 3 4 5 6 7 8
1. Penfield dissector, #1
2. Penfield dissector, #2
3. Penfield dissector, #3
4. Penfield dissector, #4
5. Penfield dissector, #5
6. Double dissector, sharp/blunt
7. Woodson elevator/spatula double end
8. Woodson separator/packer, double end
KERRISSON RONGEUR
1. Kerrisson rongeurSCISSORS
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PTERIONAL OSTEOPLASTIC CRANIOTOMY
DATE OF SURGERY:
SURGEON: Dr. X
ASSISTANT: Dr. Y
PREOPERATIVE DIAGNOSIS: (Right/Left) clinoidal mass.
POSTOPERATIVE DIAGNOSIS: (Right/Left) clinoidal
(meningioma).
PROCEDURES PERFORMED:
1. Stereotactic (Right/Left) pterional osteoplastic
craniotomy with resection of clinoidal/sphenoid wing
mass.
2. Intraoperative use of microscope for microdissection.
3. Intraoperative electrophysiological monitoring with SSEPs
and motor evoked potentials.
CPT Coding
61592 Orbitocranial zygomatic approach to middle cranial fossa
(cavernous sinus and carotid artery, clivus, basilar artery or petrous
apex) including osteotomy of zygoma, craniotomy, extra or intradural
elevation of temporal lobe
61795 Stereotactic computer‐assisted volumetric (navigational)
procedure, intracranial or spinal (List separately in addition to
primary procedure)
69990 Microsurgical techniques, requiring use of operating
microscope (List separately in addition to code for primary
procedure)
ANESTHESIA: GETA.
ESTIMATED BLOOD LOSS: (XX) cc.
FINDINGS: Frozen section was consistent with ___.
DRAINS: (JP/Blake) drain.
COMPLICATIONS: None.
DISPOSITION: Stable to the PACU.
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INDICATIONS FOR THE PROCEDURE
HISTORY: (Mr./Ms.) (Pt. Name) is a (Pt. Age) year old
(Male/Female) who presents with signs and symptoms
consistent with a clinoidal/sphenoid wing mass (double
vision, blurry vision, cranial nerve palsy). The goal of the
operation was optic and cranial nerve decompression.
DIAGNOSTIC STUDIES: MRI brain showed ___.
SURGICAL RISKS: The patient (family/N.O.K./P.O.A.) was
well apprised of all objectives, benefits, risks and potential
complications of the procedure, including but not limited
to: worsening of current status, the possible need for
further procedures, the risk of infection, headaches, CSF
leak, seizures, hemorrhage, stroke, loss of language
function, paralysis, coma and even death. Informed consent
was obtained and secured in the chart after the patient
(family/N.O.K./P.O.A.) voiced understanding of these risks
and decided to proceed with the operation.
DESCRIPTION OF THE PROCEDURE:
The patient was transferred to the operating room. (He/She)
was given preoperative prophylactic IV antibiotics.
ANESTHESIA: The patient was sedated and intubated
without difficulty by the anesthesia service. Eyes were taped
shut after ointment was applied to prevent corneal abrasion.
A Bair Hugger was placed over the exposed lower body to
maintain control of core body temperature. A Foley catheter
was inserted.
POSITIONING: A Mayfield head clamp was applied. The
patient was positioned supine with the head turned
approximately (XX) degrees to the (Right/Left) with very mild
extension. All pressure points were carefully padded. The
hair was clipped over the area where (He/She) was to
undergo the incision. Pre‐prepping was done with
(chlorhexidine solution, alcohol). The electrophysiology
monitoring team inserted needles in their proper locations
and baseline SSEPs and motor evoked potentials were
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FUNCTIONAL, EPILEPSY AND
PAIN
1. Epilepsy Surgery Stage I: Long Term Monitoring
Electrodes Placement.
2. Epilepsy Surgery Stage II: Premotor Cortex Lesion
Resection.
3. Epilepsy Surgery Stage II: Temporal Lobe Lesion
Resection.
4. Microvascular Decompression.
5. Deep Brain Stimulator Lead Placement.
6. Deep Brain Stimulator Generator Placement.
7. Rhizotomy: Medial Facet Branch.
8. Carpal Tunnel Release.
9. Ulnar Nerve Decompression.
10. Peroneal Nerve Lysis.
11. Spinal Cord Stimulator Placement.
12. Vagal Nerve Stimulator Implantation.
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SHUNTING PROCEDURES
1. Ventricular Peritoneal Shunt Placement
2. Lumbar Peritoneal Shunt Placement
3. Endoscopic Third Ventriculostomy
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SPINAL PROCEDURES
Spinal Dictations Guide
1. Anterior Cervical Discectomy and Fusion (ACDF)
2. Anterior Lumbar Interbody Fusion (ALIF)
3. Cervical Corpectomy
4. Cervical Laminectomy with Lateral Mass Arthrodesis
5. Cervical Laminoplasty
6. Extreme Lateral Interbody Fusion (XLIF)
7. Laminectomy for Intramedullary Spinal Tumor
8. Laminectomy for Excision of Intradural
Extramedullary Spinal Tumor
9. Lumbar Hemilaminectomy and Microdiscectomy
10. Lumbar Laminectomy‐ Bilateral
11. MIS Laminectomy
12. Percutaneous Discectomy
13. Posterolateral Interbody Fusion (PLIF)
14. Redo Instrumentation Removal
15. Thoracic Corpectomy Lateral Extracavitary
Approach
16. Thoracic Corpectomy Transthoracic Approach
17. X‐Stop
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Operative Dictation: Neurosurgery
SPINAL DICTATIONS GUIDE
In Neurosurgery there are a lot of spinal procedures with a
lot of different codes. These codes are constantly changing.
When using this section remember to keep in mind that you
should consult an official CPT book for accurate coding for
purposes of reimbursement.
Some procedures are performed with electrophysiological
monitoring (see Cervical Laminoplasty for example). The CPT
coding is provided here for your quick review.
CPT Coding
95929 Central motor evoked potential study (transcranial motor
stimulation); lower limbs
95928 Central motor evoked potential study (transcranial motor
stimulation); upper limbs
95926 Short‐latency somatosensory evoked potential study,
stimulation of any/all peripheral nerves or skin sites, recording from
the central nervous system; in lower limbs
95925 Short‐latency somatosensory evoked potential study,
stimulation of any/all peripheral nerves or skin sites, recording from
the central nervous system; in upper limbs
CPT Coding
20986 Computer‐assisted surgical navigational procedure for
musculoskeletal procedures; with image guidance based on
intraoperatively obtained images (eg, fluoroscopy, ultrasound) (List
separately in addition to code for primary procedure)
77002 Fluoroscopic guidance for needle placement (eg, biopsy,
aspiration, injection, localization device)
In cases where bone marrow aspirate is used during the
spinal procedure consider using the following CPT code:
CPT Coding
38220 Bone marrow; aspiration only
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ANTERIOR CERVICAL DISCECTOMY AND
FUSION
DATE OF SURGERY:
SURGEON: Dr. X
ASSISTANT: Dr. Y
PREOPERATIVE DIAGNOSIS: C(LEVEL)‐C(LEVEL) radiculopathy
and herniated cervical disc.
POSTOPERATIVE DIAGNOSIS: C(LEVEL)‐C(LEVEL)
radiculopathy and herniated cervical disc.
PROCEDURE PERFORMED:
1. C(LEVEL)‐C(LEVEL) anterior cervical discectomy with
decompression of spinal cord and osteophytectomy.
2. C(LEVEL)‐C(LEVEL) anterior interbody arthrodesis.
3. C(LEVEL)‐C(LEVEL) insertion of interbody allograft.
4. Microsurgical techniques, requiring use of operating
microscope for discectomy and osteophytectomy.
5. C(LEVEL)‐C(LEVEL) anterior plate and screws.
6. Fluoroscopic guidance for localization and
instrumentation.
CPT Coding
20931 Allograft for spine surgery only; structural (List separately
in addition to code for primary procedure)
22845 Anterior instrumentation; 2 to 3 vertebral segments (List
separately in addition to code for primary procedure)
22851 Application of intervertebral biomechanical device(s) (eg,
synthetic cage(s), threaded bone dowel(s), methylmethacrylate)
to vertebral defect or interspace (List separately in addition to
code for primary procedure)
22554 Arthrodesis, anterior interbody technique, including
minimal discectomy to prepare interspace (other than for
decompression); cervical below C2
63075 Discectomy, anterior, with decompression of spinal cord
and/or nerve root(s), including osteophytectomy; cervical, single
interspace
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Operative Dictation: Neurosurgery
CPT Coding (Cont.)
69990 Microsurgical techniques, requiring use of operating
microscope (List separately in addition to code for primary
procedure)
77002 Fluoroscopic guidance for needle placement (eg, biopsy,
aspiration, injection, localization device)
ANESTHESIA: GETA.
ESTIMATED BLOOD LOSS: (XX) cc.
FINDINGS:
DRAINS: (JP/Blake) drain.
COMPLICATIONS: None.
DISPOSITION: Stable to the PACU
INDICATIONS FOR THE PROCEDURE Mr./Ms. (Pt. Name) is a
(Pt. Age) year old (Male/Female) who presents with signs,
symptoms and radiographic evidence of (Right/Left) neck
pain radiating into (His/Her) (Right/Left) arm in a C(LEVEL)
dermatomal pattern.
DIAGNOSTIC STUDY: MRI cervical spine showed___.
(He/She) had failed conservative treatment (physical
therapy, pain medication, epidural steroids) and (His/Her)
symptoms continued to progress. Given the progression of
the symptoms, it was decided to proceed with the
decompression of the herniated disc and osteophyte
complex at C(LEVEL).
SURGICAL RISKS: The patient (family/ N.O.K./ P.O.A.) were
apprised of all objectives, benefits, risks and potential
complications of the procedure, including but not limited
to: worsening of current status, the possible need for
further procedures, the risk of infection, headaches, CSF
leak, possible spinal cord injury resulting in paralysis,
infection, neck hematoma and hoarseness of voice, injury
to major vessels causing hemorrhage, stroke, loss of
language function, coma and even death. Informed consent
was obtained and secured in the chart after the patient
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VASCULAR/ENDOVASCULAR
PROCEDURES
1. Carotid Endarterectomy
2. Cerebral Angiography
3. Cerebral Angiogram with Aneurysm Coiling
4. Cerebral Angiogram with Stent‐assisted Aneurysm
Coiling
5. Cerebral Angiogram with AVM embolization
6. Angiogram with Carotid Balloon Angioplasty and
Stent
Placement
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Operative Dictation: Neurosurgery
CEREBRAL ANGIOGRAPHY
DATE OF PROCEDURE:
RADIOLOGIST/SURGEON: Dr. X
ASSISTANT: Dr. Y
PREOPERATIVE DIAGNOSIS: (Subarachnoid hemorrhage,
carotid stenosis).
POSTOPERATIVE DIAGNOSIS: (Subarachnoid hemorrhage,
carotid stenosis).
PROCEDURES PERFORMED:
1. Bilateral (vessel) angiogram‐cervical.
2. Bilateral (vessel) angiogram‐cerebral.
3. Rotational 3D (Right/Left) (vessel) angiogram.
4. Bilateral vertebral artery angiogram‐bilateral.
5. (Right/Left) common femoral artery angiogram.
6. Deployment of a (X)‐French Angio‐Seal within the right
femoral artery.
CPT Coding
75676 Angiography, carotid, cervical, unilateral, radiological
supervision and interpretation
75671 Angiography, carotid, cerebral, bilateral, radiological
supervision and interpretation
75685 Angiography, vertebral, cervical, and /or intracranial,
radiological supervision and interpretation
75774 Angiography, selective, each additional vessel studied after
basic examination, radiological supervision and interpretation (List
separately in addition to code for primary procedure)
ANESTHESIA: IV sedation with local anesthesia.
ESTIMATED BLOOD LOSS: (XX) cc.
FLUORO TIME: (XX) minutes and (XX) seconds.
CONTRAST: Intravenous contrast agent (XX) cc.
FINDINGS:
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Operative Dictation: Neurosurgery
1. Report AVM, aneurysm remnants if clipped, vessel
stenosis.
2. Report arterial, capillary, and venous opacification on all
angiographic runs.
COMPLICATIONS: None.
DISPOSITION: Stable to the PACU.
INDICATIONS FOR THE PROCEDURE
HISTORY: (Mr./Ms.) (Pt. Name) is a (Pt. Age) year old
(Male/Female) with signs, symptoms and radiographic
evidence of (Right/Left) [(Acom, Pcom, MCA, Basilar tip)
aneurysm] or [carotid artery stenosis].
DIAGNOSTIC STUDY: MRI/CT/CTA/MRA brain showed ___.
PROCEDURE RISKS: The patient (family/N.O.K./P.O.A.) was
well apprised of all objectives, benefits, risks and potential
complications of the procedure, including but not limited
to: worsening of current status, the possible need for
further procedures, the risk of infection, seizures,
hemorrhage, stroke, loss of language function, paralysis,
coma and even death. Informed consent was obtained and
secured in the chart after the patient (family/N.O.K./P.O.A.)
voiced understanding of these risks and decided to proceed
with the procedure.
DESCRIPTION OF THE PROCEDURE
The patient was transferred to the angiography suite.
(He/She) was given preoperative prophylactic IV antibiotics.
ANESTHESIA: The patient was given IV sedation by the
anesthesia team.
POSITIONING: The patient was placed in the supine position
on the angio table. The groins were prepped and draped
bilaterally in the usual sterile fashion.
TECHNIQUE: The pulse of the common femoral artery was
felt on the (Right/Left) groin and the overlying skin was
infiltrated with (XX) % lidocaine. A stiff micropuncture set
was utilized to gain access to the vessel. Pulsatile bright red
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Operative Dictation: Neurosurgery
MINOR PROCEDURES
1. Arterial Line Placement
2. Lumbar Spinal Puncture
3. Lumbar Drain Placement
4. Ventriculostomy Placement
5. Vertebroplasty/ Kyphoplasty
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Operative Dictation: Neurosurgery
APPENDIX
Hydrogel dural sealant (DuraSeal)
Oxidized cellulose absorbable hemostat (Surgicel)
Synthetic cotton absorbant sponge (Cottonoid)
Polyglactin synthetic absorbable suture (Vicryl)
Non‐absorbable braided polyamide suture (Nurolon)
Absorbable gelatin compressed sponge (Gelfoam)
Microfibrillar collagen hemostat (Avitene)
Poliglecaprone 25 (Monocryl)
Adhesive skin closure (Steri‐Strips)
Synthetic non‐absorbable polypropylene suture (Prolene)
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Operative Dictation: Neurosurgery
ABBREVIATIONS
ACA = Anterior cerebral artery
Acom = Anterior communicating artery
AP = Anterior‐Posterior
BMP = Bone morphogenic protein
C = Cervical
CSF = Cerebrospinal fluid
CT = Computed tomography
CT = Computed tomographic angiography
CUSA = cavitron ultrasonic aspirator
GETA = General endotracheal anesthesia
L = Lumbar
MEP = Motor‐evoked potentials
MCA = Middle cerebral artery
MRA = Magnetic resonance angiography
MRI = Magnetic resonance imaging
NOK = Next of kin
PCA = Posterior cerebral artery
Pcom = Posterior communicating artery
POA = Power of attorney
S = Sacral
SSEP = Somotosensory‐evoked potentials
T = Thoracic
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