The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Lateral (including extreme, extra and direct lateral) interbody fusion in the lumbar spine.

  • Description

    As a person gets older, the discs between the back bones that provide support can deteriorate because of wear and tear. Sometimes this causes such severe pain and disability that surgery is considered.

    Lateral interbody spinal fusion involves the removal of all, or part, of the damaged disc and the insertion of a supportive structure, together with a fragment of bone from the hip. It aims to join the two back bones together to prevent movement of the painful joint. The procedure is done through a cut in the patient’s side.

  • OPCS4.6 Code(s)

    V33.8 Other specified primary excision  of lumbar intervertebral disc

    V55. - Levels of spine

    Y53.4 Approach to organ under fluoroscopic control

    V38.8 Other specified primary fusion of other joint of spine

    V55. - Levels of spine

    Y53.4 Approach to organ under fluoroscopic control

    Z67.5 Lumbar intervertebral joint

    Codes within category V55.- are assigned in second place each time a spinal operation is coded. If the levels of spine are not specified V55.9 Unspecified levels of spine is used.

    Codes within category Y53.- are used as secondary codes to classify interventions that are percutaneous and require some form of image control, if the method of image control is unspecified Y53.9 Unspecified approach to organ under image control is assigned.

    It is not possible to indicate that a lateral approach has been used during this procedure using OPCS-4 codes.

    The NHS Classifications Service of NHS Connecting for Health is the central definitive source for clinical coding guidance and determines the coding standards associated with the classifications (OPCS-4 and ICD-10) to be used across the NHS.   The NHS Classifications Service and NICE work collaboratively to ensure the most appropriate classification codes are provided.

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