Artrodese vertebral sem enxerto ósseo

"Como se codifica a artrodese vertebral em que não se utiliza cage, enxerto ósseo ou qualquer outro substituto?
 É que as barras e os parafusos não são propriamente "Synthetic Substitute"..."

(Responde Fernando Lopes)
 


A artrodese vertebral é a imobilização de uma (ou mais) articulações vertebrais.
A "fusão" que resulta da artrodese implicará uma continuidade óssea entre as vértebras fundidas.
Diz a ICD-10-PCS:
 
Definition: Joining together portions of an articular body part rendering the articular body part immobile
Explanation: The body part is joined together by fixation device, bone graft, or other means
Includes/Examples: Spinal fusion, ankle arthrodesis
 
Na ICD-10-PCS a root operation Fusion prevê os seguintes Devices:
A Interbody Fusion Device
7 Autologous Tissue Substitute
J Synthetic Substitute
K Nonautologous Tissue Substitute
Z No Device
 
E como podem ser aplicadas várias combinações de materiais, as Guidelines explicam:
 
Guideline B3.10c
Combinations of devices and materials are often used on a vertebral joint to render the joint immobile. When combinations of devices are used on the same vertebral joint, the device value coded for the procedure is as follows:

• If an interbody fusion device is used to render the joint immobile (alone or containing other material like bone graft), the procedure is coded with the device value Interbody Fusion Device
  
• If bone graft is the only device used to render the joint immobile, the procedure is coded with the device value Nonautologous Tissue Substitute or Autologous Tissue Substitute
  
• If a mixture of autologous and nonautologous bone graft (with or without biological or synthetic extenders or binders) is used to render the joint immobile, code the procedure with the device value Autologous Tissue Substitute
  

Esta Guideline não contempla a artrodese realizada apenas com material de fixação (barras e parafusos) porque este material está incluído na codificação da artrodese e não se codifica à parte.
 
A este propósito o Coding Clinic já se pronunciou:
 
“Additionally to an Interbody Fusion Device, the fixation instrumentation (i.e., rods, plates, screws, etc.) is included in the fusion root operation, and no additional code is assigned." (Coding Clinic 2Q 2014 p.
 
"The explanation in the root operation for fusion states “that body part is joined together by fixation device, bone graft, or other means.” Therefore, the fixation (rods, plates, screws) is included in the fusion root operation, and no additional code is assigned." (Coding Clinic 3Q 2014 p.32)
 
"A spinal fusion ...  with lateral mass screws ... placed from C3-C6 bilaterally with connecting rods...  and no documentation of bone graft or a bone graft substitute being utilized... does not constitute a spinal fusion. Spinal fusion involves the use of bone graft or bone graft substitute, which can be done with or without instrumentation" (Coding Clinic 2Q 2017 p.25)
 
Para uma "atrodese" realizada só com barras e parafusos temos a opção da Insertion (?)
Por exemplo para a coluna torácica, na tabela 0HR, Insertion, Upper Joints, está prevista a inserção dos seguintes "fixadores":

• 4 Internal Fixation Device
  
• B Spinal Stabilization Device, Interspinous Process
  
• C Spinal Stabilization Device, Pedicle-Based
  
• D Spinal Stabilization Device, Facet Replacement
  

Teremos de rever o conceito de artrodese (vs Fusion)...
A ajuda dos colegas (codificadores) da especialidade será bem vinda!
 
 
Fernando Lopes