1100 W Oakland Park Blvd Suite #3
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Medical School: Harvard Medical School - 1996
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|HCPCS Code||Description||Average Price||Average Price
Allowed By Medicare
|HCPCS Code:99205||Description:Office/outpatient visit new||Average Price:$1,000.00||Average Price Allowed
|HCPCS Code:99214||Description:Office/outpatient visit est||Average Price:$517.16||Average Price Allowed
HCPCS Code Definitions
- Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
Medical Malpractice Cases
Medical Board Sanctions
Biomechanics of posterior instrumentation in L1-L3 lateral interbody fusion: Pedicle screw rod construct vs. transfacet pedicle screws. - Clinical biomechanics (Bristol, Avon)
The use of pedicle screws is the gold standard for supplemental posterior fixation in lateral interbody fusion. Information about the performance of transfacet pedicle screws compared to standard pedicle screws and rods in the upper lumbar spine with or without a lateral interbody fusion device in place is limited.Fifteen fresh frozen human cadaveric lumbar spine segments (T12-L4) were studied using standard pure moment flexibility tests. Specimens were divided into two groups to receive either bilateral transfacet pedicle screws (n=8) or bilateral pedicle screws (n=14). Stability of each motion segment (L1-L2 and L2-L3) was evaluated intact, with posterior instrumentation with an intact disc, with posterior instrumentation and a lateral interbody fusion device in place, and following cyclic loading with the interbody device and posterior instrumentation still in place. Both raw values of motion (range of motion, lax zone and stiff zone) and normalized mobility (ratios to intact) were analyzed for each case.In terms of immediate stability, transfacet pedicle screws performed equivalent to similarly sized pedicle screws, both with intact disc and with lateral interbody fusion device in all directions of loading. Stability following cyclic loading decreased significantly during lateral bending and axial rotation.Posterior fixation with transfacet pedicle screws provides equivalent immediate stability to similarly sized pedicle screws. However, in the presence of a lateral interbody fusion device, pedicle screws seem to resist loosening more and may be a better option for fusion in the upper lumbar spine.Copyright Â© 2015. Published by Elsevier Ltd.
Feasibility and patient-reported outcomes after outpatient single-level instrumented posterior lumbar interbody fusion in a surgery center: preliminary results in 16 patients. - Spine
Retrospective study.To report surgical and patient-reported outcomes after outpatient lumbar fusions in an ambulatory setting.There is growing interest in the potential benefits of outpatient spine surgery such as reduced costs, consistent operative team, and decreased postoperative complications during in-hospital recovery. However, there are limited studies on outcomes after outpatient lumbar fusions, to guide patient selection, treatment techniques and postoperative expectations.Medical records of 16 consecutive patients, who underwent outpatient direct open, single-level, posterior lumbar interbody fusions, were examined by a single surgeon. Outcome measures included visual analogue scale (VAS) scores for lower back and Oswestry Disability Indices (ODIs). Mean body mass indices (BMIs), estimated blood loss, surgical times and complications, and fusion rates were evaluated.Males represented 56% of patients. Mean age was 42.81 Â± 3.05 years (mean Â± standard error) and mean body mass index was 28.95 Â± 1.04. History of smoking and narcotics use were statistically noncontributory. Mean final follow-up was 15 (range, 5.52-34.2 mo) months. Mean postoperative scores were determined by the final follow-up VAS and ODI. L5-S1 was the most common level of the 16 levels operated on (69%). Preoperative and postoperative VAS and ODI scores for lower back were obtained for 15 patients (93.75%). Mean lower back VAS score of 8.4 Â± 0.37 preoperatively reduced to 4.96 Â± 0.73 postoperatively, (P = 0.001). Mean ODI improved from 52.71 Â± 0.04 preoperatively, to 37.43 Â± 0.06 postoperatively, (P = 0.04). One patient experienced postoperative worsened back pain with clinical and radiological signs of possible aseptic discitis. Estimated blood loss was 161 Â± 32 mL and average operating time was 124.85 Â± 7.10 minutes. The overall fusion rate was 87.5%.Direct open posterior lumbar interbody fusions were done safely with statistically significant reduction in average pain and ODI scores. Surgical times were approximately 2 hours with minimal blood loss, allowing patients to be comfortably discharged the same day without a drain.
Safety and usefulness of free fat grafts after microdiscectomy using an access cannula: a prospective pilot study and literature review. - American journal of orthopedics (Belle Mead, N.J.)
Placing an interpositional fat graft over the dura has been practiced to prevent sciatica due to nerve tethering from scar. We assessed feasibility, outcomes, and complications of free fat grafts in patients undergoing lumbar microdiscectomy for herniated discs using an access cannula. Retrospective review of prospectively collected data on 69 consecutive patients: those who received autologous fat graft (Group I) and those who did not (Group II). Clinical evaluation of leg pain and nerve tension sign was performed in the immediate postoperative period and at 1 month, 6 months, 12 months, and 24 months. The combined visual analog scale (VAS) scores for leg pain improved from 8.3 preoperatively to 1.3 (P < 0.5). The average VAS score for leg pain was 1.4 (0 to 3) in Group I and 1.3 (0 to 3) in Group II (P > 0.05). Ninety-one percent had resolution of their leg pain immediately postop and 96% at final follow-up. This study found no increased complications with the use of fat graft, but no clinical benefit, therefore the use of fat graft should be discouraged. The potential complication with the use of fat graft is the "mass effect" on the dura, and therefore, the width of the graft should be <1 cm.
Stability of transforaminal lumbar interbody fusion in the setting of retained facets and posterior fixation using transfacet or standard pedicle screws. - The spine journal : official journal of the North American Spine Society
The transforaminal lumbar interbody fusion (TLIF) technique supplements posterior instrumented lumbar spine fusion and has been tested with different types of screw fixation for stabilization. Transforaminal lumbar interbody fusion is usually placed through a unilateral foraminal approach after unilateral facetectomy, although extraforaminal entry allows the facet to be spared.To characterize the biomechanics of L4-L5 lumbar motion segments instrumented with bilateral transfacet pedicle screw (TFPS) fixation versus bilateral pedicle screw-rod (PSR) fixation in the setting of intact facets and native disc or after discectomy and extraforaminal placement of a TLIF technology graft.Human cadaveric lumbar spine segments were biomechanically tested inÂ vitroÂ to provide a nonpaired comparison of four configurations of posterior and interbody instrumentation.Fourteen human cadaveric spine specimens (T12-S1) underwent standard pure moment flexibility tests with intact L4-L5 disc and facets. Seven were studied with intact discs, after TFPS fixation, and then with TLIF and TFPS fixation. The others were studied with intact discs, after PSR fixation, and then combined with extraforaminally placed TLIF. Loads were applied about anatomic axes to induce flexion-extension, lateral bending, and axial rotation. Three-dimensional specimen motion in response to applied loads during flexibility tests was determined. A nonpaired comparison of the four configurations of posterior and interbody instrumentation was made.Transfacet pedicle screw and PSR, with or without TLIF, significantly reduced range of motion during all directions of loading. Transfacet pedicle screw provided greater stability than PSR in all directions of motion except lateral bending. In flexion, TFPS was more stable than PSR (p=.042). A TLIF device provided less stability than the intact disc in constructs with TFPS and PSR.These results suggest that fixation at L4-L5 with TFPS is a promising alternative to PSR, with or without TLIF. A TLIF device was less stable than the native disc with both methods of instrumentation presumably because of a fulcrum effect from a relatively small footplate. Additional interbody support may be considered for improved biomechanics with TLIF.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Ideal starting point and trajectory for C2 pedicle screw placement: a 3D computed tomography analysis using perioperative measurements. - The spine journal : official journal of the North American Spine Society
C2 pedicle screws provide stable fixation for posterior cervical fusion. Placing C2 pedicle screws is fraught with risks, and a misplaced screw can result in cortical breach of the pedicle, resulting in injury to the vertebral artery or spinal cord.We sought to identify a reproducible starting point and trajectory for C2 pedicle screw placement using three-dimensional (3D) computed tomography (CT) imaging. Our aims included identifying correct cephalad and mediolateral angles used for determining the most accurate trajectory through the C2 pedicle.A radiographic analysis of the anatomy of the C2 pedicle using CT.A random sample of 34 cervical spine CT scans in patients without medical or surgical pathology of the cervical spine.Normal anatomic measurements made in the axial and sagittal planes of the CT scans. Angles and measures in millimeters were recorded.The C2 pedicles were evaluated using CT scanning with a 3D imaging application. The ideal trajectory through each pedicle was plotted. The mediolateral and cephalad angles were measured using the midline sagittal plane and the inferior vertebral body border as references. Other measurements made were the distances through the pedicle and vertebral bodies, and the surface distances along the laminae between the isthmus and the starting point of the chosen trajectories. Other measurements involving the height of the laminae were also made. The mean values, standard deviations, and intraobserver variations are presented.CT scans from 34 patients were reviewed. The sex of the patient did not predict angle measurements (p=.2038), so combined male and female patient measures are presented. The mean mediolateral angle measured was 29.2Â°, and the mean cephalad angle was 23.0Â°. The mean distance along the lamina surface between the isthmus and the starting point was 8.1 mm. The mean distance from the superior border of the lamina to the starting point was 5.7 mm. There were no statistically significant differences between the dataset collected in duplicate by the same observer (p=.74); as such, we present one data analysis on combined data from the two datasets collected.It is possible to determine an ideal trajectory through the C2 pedicle. These measurements may facilitate C2 pedicle screw fixation decreasing the risk of injury to the vertebral artery, spinal cord, or nerve roots. Delineating the individual anatomy in each case with imaging before surgery is recommended.Copyright Â© 2014 Elsevier Inc. All rights reserved.
Avoidance of Wrong-Level Thoracic Spine Surgery Using Sterile Spinal Needles. - Journal of spinal disorders & techniques
A technical report.To present an improvement on localization techniques employed for use in the thoracic spine using sterile spinal needles docked on the transverse process of each vertebra, which can be performed in both percutaneous and open spinal procedures.Wrong level surgery may have momentous clinical and emotional implications for a patient and surgeon. It is reported that one in every two spine surgeons will operate on the wrong level during his or her career. Correctly localizing specific thoracic level remains a significant challenge during spine surgery.Fluoroscopic anteroposterior and lateral views were obtained starting in the lower lumbar spine and an 18-gauge spinal needle was placed in the transverse process of L3 counting up from the sacrum and also at T12. The fluoroscopy was then moved cephalad and counting from the spinal needle at T12 the other spinal needles were placed at the targeted operating thoracic vertebrae. Once this was done, we were able to accurately determine the thoracic levels for surgical intervention.Using this presented technique, the markers were kept in place even after the incisions were made. This prevented us from losing our location in the thoracic spine. Correctly placed instrumentation was made evident with postoperative imaging.We have described the successful use of a new technique using spinal needles docked against transverse processes to correctly and reliably identify thoracic levels prior to instrumentation. The technique was reproducible in both open surgeries and for a percutaneous procedure. This technique maintains the correct spinal level during an open procedure. We posit that wrong level thoracic spine surgery may be preventable.
Effects of misalignment on static torsional strength of anterior cervical plate systems. - The spine journal : official journal of the North American Spine Society
There is little understanding of cervical plate misalignment as a risk factor for plate failure at the plate-screw-bone interface.To assess the torsional strength and mode of failure of cervical plates misaligned relative to the midsagittal vertical axis.Plastic and foam model spine segments were tested using static compression and torsion to assess effects of misaligned and various lengths anterior cervical plate (ACPs).Different length ACPs and cancellous fixed angle screws underwent axial torsional testing on a servo-hydraulic test frame at a rate of 0.5Â°/s. A construct consisted of one ACP, four screws, one ultrahigh-molecular weight polyethylene inferior block, and one polyurethane foam superior block. Group 1 had ACPs aligned in the midsagittal vertical axis, group 2 plates were positioned 20Â° offset from the midline, and group 3 had the ACP shifted 5 mm away and 20Â° offset from midline. Torques versus angle data were recorded. The failure criterion was the first sign of pullout determined visually and graphically.Group 1 had a more direct screw pullout during failure. For the misaligned plates, failure was a combination of the screws elongating the holes and shear forces acting between the plate and block. The misaligned plates needed more torque to failure. The failure torque was 50% reduced for the longer versus the shorter plates in the neutral position. Graphically shown initial screw slippage inside the block preceded visual identification of slippage in some cases.We observed different failure mechanisms for neutral versus misaligned plates. Clinically, misalignment may have the benefit of needing more torque to fail. Misalignment was a risk factor for failure of the screw-bone interface, especially in longer plate constructs. These comparisons of angulations may be a solid platform for expansion toward a more applicable in vivo model.Copyright Â© 2013 Elsevier Inc. All rights reserved.
"White cord syndrome" of acute tetraplegia after anterior cervical decompression and fusion for chronic spinal cord compression: a case report. - Case reports in orthopedics
Paralysis is the most feared postoperative complication of ACDF and occurs most often due to an epidural hematoma. In the absence of a clear etiology, inadequate decompression or vascular insult such as ischemia/reperfusion injury are the usual suspects. Herewith we report a case of complete loss of somatosensory evoked potentials (SSEPs) during elective ACDF at C4-5 and C5-6 followed by postoperative C6 incomplete tetraplegia without any discernible technical cause. A postoperative MRI demonstrated a large area of high signal changes on T2-weighted MRI intrinsic to the cord "white cord syndrome" but no residual compression. This was considered consistent with spinal cord gliosis with possible acute edema. The acute decompression of the herniated disc resulted in cord expansion and rush-in reperfusion. We postulate that this may have led to disruption in the blood brain barrier (BBB) and triggered a cascade of reperfusion injuries resulting in acute neurologic dysfunction. At 16 months postoperatively our patient is recovering slowly and is now a Nurick Grade 4.
Postoperative cervical haematoma complicated by ipsilateral carotid thrombosis and aphasia after anterior cervical fusion: a case report. - Case reports in medicine
Hematoma alone is the most common vascular complication reported after anterior cervical decompression and fusion (ACDF). We present this case to report the occurrence of postoperative cervical hematoma complicated by ipsilateral carotid thrombosis and aphasia after an uncomplicated C4-6 ACDF. This is a case of a 65-year-old woman who underwent revision fusions of the C4-5 and C6-7 levels complicated by postoperative cervical hematoma and carotid thrombosis. The patient's history, clinical examination, imaging findings, and treatment are reported. The revision fusions were performed and deemed routine. Approximately eight hours later 200â€‰mL of blood was evacuated from a postoperative cervical hematoma. The patient became unresponsive and disoriented a few hours after evacuating the hematoma. Computed tomography and magnetic resonance imaging of the brain were normal, but magnetic resonance angiography demonstrated total occlusion of the left carotid artery. Thrombectomy was performed and the patient was discharged without residual deficits. At the latest followup she is fully functional and asymptomatic in her neck. We suggest, after evacuating a cervical hematoma, an evaluation of the carotids be made with MRA or cerebral angiography, as this may demonstrate a clot before the patient develops symptoms.
Mini-open or percutaneous bilateral lumbar transfacet pedicle screw fixation: a technical note. - Journal of spinal disorders & techniques
Case report.To describe the technique used to place bilateral lumbar transfacet pedicle screws.Transfacet pedicle screw fixation is a growing alternative and biomechanically comparable with traditional pedicle screw fixation. There is no clear description of technique steps for placing transfacet pedicle screws available in the literature, despite recognizing that screw placement is not intuitive even with fluoroscopy, and is dissimilar to placing traditional pedicle screws or translaminar facet screws.We present 2 illustrative cases where bilateral transfacet pedicle screws were placed for posterior instrumentation after a step-by-step technique that can be used in a mini-open or percutaenous procedure.Postoperatively, both patients had adequately placed transfacet pedicle screws bilaterally on x-ray imaging with 1 patient demonstrating fusion and intact fixation at 11 months follow-up.Transfacet pedicle screws were successfully placed in 2 patients in a stepwise technique described to achieve lumbar fusion.
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