The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Transaxial interbody lumbosacral fusion.

  • Description

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

    Transaxial interbody lumbosacral fusion is done through a small cut over the bony structure at the base of the spine connected to the pelvis. It involves removing all, or part, of the damaged disc and inserting an artificial implant and bone graft material into the remaining disc space. The aim is to encourage two spine bones to join together to prevent movement of the painful joint.

  • OPCS4.6 Code(s)

    V33.8 Other specified primary excision  of lumbar intervertebral disc

    V55. 1 One level of spine

    Y53.4 Approach to organ under fluoroscopic control

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

    V55. 1 One level of spine

    Y53.4 Approach to organ under fluoroscopic control

    Z67.6 Lumbosacral 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.

    Supplemental posterior instrumentation to provide additional stabilisation and vertebral body spinal fusion of other levels with alternative approaches may be coded in addition depending on the type of instrumentation/stabilisation used or the type of vertebral body spinal fusion and approaches used.

    It is not possible to indicate that a transaxial approach was used during this procedure using OPCS-4 codes.

    The NHS Classifications Service has advised NICE that currently these are the most suitable OPCS-4 codes to describe this procedure. The OPCS-4 classification is designed to categorise procedures for analysis and it is not always possible to identify a procedure uniquely.

    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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