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. 4.6Sexual 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 al eci
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
MATERIAL SAFETY DATA SHEET Finished Product SECTION 1 - CHEMICAL SUBSTANCE/PRODUCT AND COMPANY IDENTIFICATION • Finished Product Name : DDF Discoloration Reversal-Pod (98898381) • Company Identification : Dist. by HDS Labs, Inc. New York, NY 10022 Contact: Consumer Relations at 1-800-818-9770 • In case of medical emergencies, please contact your local poison control c
Leben mit dem Todesurteil Mein Brustkrebs und seine Lungenmetastasen Ein Jahr ist es her, dass ich von den Ärzten der Bonner Robert-Janker-Krebsklinik vonmeinen fünf Lungenmetastasen erfuhr. “Ist dies ein Todesurteil?” fragte ich siefassungslos. Sie nickten betreten: “Metastasierender Brustkrebs ist nicht heilbar, nurnoch palliativ zu behandeln.” Vor allem, wenn sich die Krebszell