MS ProceduresMS ProceduresDx and TxDx and Tx

MHAMHA

June 11, 2009June 11, 2009

Irene Mueller, EdD, RHIAIrene Mueller, EdD, RHIA

Objectives Objectives

• 1st hour – Common MS Therapies – Diagnostic Procedures– Pharmaceuticals– Physical Therapy– Therapeutic Procedures

• 2nd hour – Coding Common MS Tx– ICD-9-CM – CPT coding

• Resources

Diagnostic Imaging Diagnostic Imaging

• X-rays– Planes of Views– Positioning – Projection– Procedures

X-ray Planes of ViewX-ray Planes of View

• Coronal/Frontal Plane (Ventral; Dorsal)– Vertically divides body into

• Front and back; anterior/ventral; posterior/dorsal

• Sagittal Plane– Vertically divides body into right and left halves– Midsagittal – midline; two equal halves

• Transverse (Horizontal/Axial)– Horizontally divides body into

• Superior/inferior OR cranial/caudal

Positioning & ProjectionPositioning & Projection

• Positioning is based on the part of the body that is closest to x-ray film

• Projection is the path that the beams take through the body

• PA = Posteroanterior projection

• AP = Anteroposterior

• Lat = Lateral or side view

• LPO = Left posterior oblique

MS X-ray ProceduresMS X-ray Procedures

• Arthrography– X-ray of joint after contrast material injection

• Computed axial tomography (CT/CAT)– X-rays of “slices” of body– Processed to make 3-D images

• Fluoroscopy– Continuous x-ray beam creates “movie”– Used for invasive procedures/operations– Adjustments

• Magnetic Resonance Imaging (MRI)– Noninvasive, 2-D, spinal cord, etc.

Bone ScansBone Scans• Used to dx

– Fractures – Arthritis – Paget disease of bone – Bone tumors – Infection of joints, replacements,

or bone (osteomyelitis) – Fibrous dysplasia – Avascular necrosis or impaired

bone blood supply – Unexplained bone pain – Metastatic ca from lung, breast,

prostate, etc.

• Nuclear medicine procedure– Uses tracers (radionuclides). – Tracers emit a type of

radiation called gamma waves

• Two Parts – Injection– Scan

• # of phases may be ordered

• SPECT sometimes ordered– Single Photon Emission

Computerized Tomography– Visualizes anatomy AND

function

DensitometryDensitometry

• Dual energy X-ray absorptiometry (DXA, DEXA) • Bone density test

– Special X-rays to measure # of grams of calcium and other bone minerals in a segment of bone

– Usually done on bones most likely to break because of osteoporosis

• Lumbar vertebrae (central)• Neck of femur • Wrist and forearm• Heel, finger (peripheral) (screening)

DEXADEXA• Results

– T-score = bone density compared to expected in healthy young adult of same sex.

• Number of units — standard deviations (SD) — that bone density is above or below the standard

• Above -1 = Normal• Between -1 and -2.5 = Osteopenia• Below 2.5 = Osteoporosis

– Z-score = number of SDs above or below what's normally expected for someone of similar

• Age, sex, weight, and ethnic or racial origin

Interpreting T-scores and Z-scoresInterpreting T-scores and Z-scores

http://www.mayoclinic.com/health/medical/IM03587

Procedural TestsProcedural Tests

• Bone bx

• Myelography

• Aspiration from joint/bursa– Arthrocentesis

Bone BiopsyBone Biopsy• Bone biopsy

– Removal of part of actual bone• Open• Fine-needle aspiration (closed) • Core needle biopsy (closed)

– Local/general anesthetic is used– Small (1/8 inch) cut in the skin

(closed)– Special drill needle is usual – Bx needle is pushed/twisted into

bone• Bone marrow exam = both

– Bone marrow bx – more solid part– Bone marrow aspiration – liquid

• Dx – Difference between

ca, non-ca tumors– Bone pain &

tenderness, if x-ray, CT scan, or other testing reveals a problem

– Osteomalacia– Osteomyelitis– Paget Disease of

bone– Rickets

http://www.webmd.com/a-to-z-guides/bone-biopsy

MyelographyMyelography• Dx

– Spinal tumors– Spinal cord swelling, Spinal nerve injury– Fractures, Back or leg pain

• Procedure– Local anesthetic– Positioned to open spaces between vertebrae– Contrast is administered– Fluoroscope (combines an x-ray with TV) takes images

• Mostly replaced by MRI -safer, simpler, more detailed• Myelography w/ CT

– When more detail of spinal canal & bone needed – If MRI not available/isn’t safe (person w/ heart pacemaker)

ArthrocentesisArthrocentesis

• Using a needle to remove synovial fluid– Can be Tx also– Effusion

• Dx– Septic arthritis

http://jama.ama-assn.org/cgi/reprint/297/13/1510.pdf

PTPT

• MS and neuro insults• Traumas• Post-surgery• Sports/Work injuries• Aging process• Poststroke/other

neuro

• Assessment– Gait, posture, ROM,

reflexes, strength, physical insult

• Plan/Goals/Time• Improve use of bones,

joints, muscles, nerves• Reduce pain levels• Prevention of disability

PT TxPT Tx• Exercise• Heat• Light• Massage• Ultrasound• Electrical stimulation• Aquatic tx

• Pt Education– Body Mechanics– Posture– Motion– Home exercise

• Assist devices– Ambulation/customized

• Crutches• Walker• Cane walking

Orthopedic AftercareOrthopedic Aftercare

• Usually for removal of wires, pins, plates, external fixation devices (Planned)

• Other tissue and healing monitored

MS DrugsMS Drugs

• MS Pharmacology– Analgesics

• Non-narcotic• Narcotic

– Anti-inflammatories– Muscle relaxants (HO)– Anti-seizure meds

AnalgesicsAnalgesics

• Non-narcotic– OTC

• Acetaminophen• NSAIDs

– Non-Steroidal Anti-Inflammatory Drugs

– Aspirin, Naproxen, Ibuprofen

– Prescription• COX2 inhibitors (NSAID)

– Celebrex, Mobic– Less gastric upset

– Prostaglandin Inhibitors (HO)

• Narcotic– Morphine– Codeine

• Controlled Substances Act of 1970 (HO)

Muscle RelaxantsMuscle Relaxants• Acute Pain

– Begins suddenly, usually sharp in quality

– Warns of disease/threat– Surgery

• Broken bones • Dental work • Burns or cuts • Labor/childbirth

• Usu. acute pain < 6 mos.• Disappears once etiology

treated/healed

• vs. Chronic Pain– Persists after healing – Pain - weeks, months, years – Physical effects include

• Tense muscles, limited mobility, lack of energy, appetite changes

– Emotional effects include • Depression, anger, anxiety, and

fear of re-injury • inability to work/enjoy leisure

– Common chronic pain complaints

• Headache • Pain - Low back, CA, Arthritis• Pain – Neurogenic, Psychogenic

•See HO for Chronic Pain Meds

MS ProceduresMS Procedures

FracturesFractures

• Reduction/Manipulation– Closed– Open

• Fixation– Internal– External– Traction

ReductionReduction

• Simple manipulation

• Closed reduction– Usu. w/radiologic guidance OR– Before/After x-rays

• Open reduction– Extending open wound/another incision– Debridement often required

• Application of fixation/traction devices

Internal FixationInternal Fixation

• Internal– Use of pins, screws, staples, rods, plates

• Hardware

– Incision and Insertion into bone for alignment– Can be done without manipulation

• Fx is aligned• Reinsertion due to displacement/breakage

– Open (ORIF) or Closed (small incision does not make open)

External FixationExternal Fixation

• Usually non-invasive

• Includes traction/immobilization (casts, etc)

• Can apply external fixation WITHOUT reduction

• Using wires (Kirschner) or pins (Steinmann) does NOT make internal fixation

Mini-FixatorMini-Fixator

• External fixator device

• Requires anesthesia

• Holes drilled proximal and distal

• Pins inserted thru bone and attached to frame

http://www.sushrut.com/img_umex_foot.jpg

Types of TractionTypes of Traction

• Skin traction– Tape, foam, felt;

longitudinal force

• Skeletal traction– Into/through bone;

force to long bones– Wires/pins

transversely thru bone, exit thru skin

• Cervical spinal – Baron tongs, Crutchfield

tongs, halo skull

• Upper extremity – Dunlap skin traction

• Lower extremity– Buck extension skin,

Charnley unit, Hamilton-Russell, balanced suspension, fixed skeletal

DislocationsDislocations

• Reduction– Dr procedure w/in 15-30 minutes – After that, under general anesthesia– Pts may be trained for recurrent dislocation– Shoulder most common joint – Recurrent most common type in ERs

• Surgery for recurrent dislocation/joint weakness– Tighten ligaments

http://www.cfpc.ca/cfp/2002/Mar/_images/Fig2b.jpg

Sprains and StrainsSprains and Strains• RICE (Rest, Ice, Compression, Elevation)

– 1st 24-72 hours after injury– R – no weight-bearing for 1st 24 hours– I – ice pack ASAP, 20/30 minutes every 2 hrs

• Remove when numb

– C – elastic bandage– E – limits circulation

• Minimizes swelling and limits internal bleeding

• Cast/Splint• Surgery if sprain is large tear/heals poorly

Sprain SurgerySprain Surgery

• Knee– ACL (2 in each knee)

• Repair (reattaching ligament to bone, avulsion fx)• Reconstruction (autograft or allograft)• Open or Arthroscopic

• Ankle– Lateral Ligament (Grade III = complete rupture

• Wrist– Several Ligaments– Arthroscopic repairs

Bunion (Hallux Valgus)Bunion (Hallux Valgus)

• Conservative tx– Roomy shoes w/lower heels– Padding, ice– Analgesics/antipyretics– Intra-articular corticosteroids injection

• Surgical Tx– Bunionectomy– Osteotomy– Arthroplasty

BunionectomyBunionectomy

• Many types (Eponyms)– Term used generically to include

• Osteotomy and arthroplasty

• Simple bunionectomy (Exostectomy)– Removing bony growth and related soft tissue– Often done in combination w/other procedures– Silver

• Modified McBride bunionectomy– Removal of bunion, rebalancing of the big toe joint by

releasing the tight tendons on the lateral side– Tightening the joint capsule on the medial side– Sometimes removing one of the sesamoid bones 

Bunion OsteotomyBunion Osteotomy

• Many types

• More severe the bunion, more proximal the osteotomy on the metatarsal bone– Distal = less of an angle of divergence – Proximal = more of an angle

Bunion OsteotomyBunion Osteotomy

• Keller procedure– Combined soft tissue release– Removal of the medial eminence with– Resection of the proximal end of proximal phalanx

• Akin procedure - hallux valgus interphalangeus – Deformity is located at the interphalangeal joint– Medially based closing-wedge osteotomy of the proximal

phalanx – Medial eminence of the metatarsal head is resected– Medial capsular reefing is done  – Usually performed w/ Silver or McBride procedure

Bunion OsteotomyBunion Osteotomy• First metatarsal head osteotomy

– Most commonly performed bunionectomy– Depends on perceived etiology of the condition and amount

of correction required 

• Chevron (Austin) osteotomy – Younger patient, no joint arthrosis, mild/moderate deformity

• involves a "V" shaped osteotomy of the distal metatarsal• allows the first metatarsal head to be shifted laterally

– Proximal metatarsal osteotomy for hallux valgus is indicated for patients with moderate to severe deformities

– May be combined w/ Silver or McBride

Bunion OsteotomyBunion Osteotomy

• Mitchell bunionectomy – Moderate to severe deformities of the

intermetatarsal angle and hallux valgus – Metatarsal osteotomy that displaces

metatarsal head laterally   – More proximal than the Chevron osteotomy,

can correct more severe deformities than Chevron

• Myerson/Ludloff

Bunion Lapidus procedureBunion Lapidus procedure

• Joint between the first metatarsal and the cuneiform bone is fused with screws (arthrodesis)

Bunion ArthroplastyBunion Arthroplasty

• Dx = Patients with arthritis of the big toe joint associated with a bunion deformity – Fusion of the joint or by – Removing a portion of the joint (arthroplasty)

• Excision arthroplasty – One or both articular ends of the bones are excised– Gap is created between them – Gap fills with fibrous tissue, or a pad of muscle or other

soft tissue may be sewn in between the bones– Interposed tissue allows ROM, but joint often lacks

stability.

BursitisBursitis

• Tx based on infectious/noninfectious dx

• Conservative tx– RICE (no ice for chronic)– Anti-inflammatories– Orthoses– Exercises– Massage– Diathermy - deep-heat tx

• Non-infectious bursitis– Aspiration (dx, tx)– Injection of corticosteriod

• Infectious bursitis– Staph/Strep less common– Antibiotics

• IV sometimes

– Surgical Drainage– Surgical Excision of

bursa/calcifications• Bursectomy

Bursitis - CorticosteriodsBursitis - Corticosteriods

• Injections into bursa– Methylprednisolone – Triamcinolone, etc.

• Iontophoresis– Using an electrical current to push a

corticosteroid medication through the skin directly over the inflamed bursa or tendon

Bursitis SurgeryBursitis Surgery

• Depends on location of bursitis

• Can be arthroscopic or open

• Open drainage with excision of the bursa

• Partial bursectomy (posterior wall)

KneeKnee

• Arthroscopy

• Arthroplasty

http://www.nlm.nih.gov/medlineplus/ency/presentations/100117_1.htm

Knee ArthroscopiesKnee Arthroscopies

• Diagnostic vs. Therapeutic• Lateral, Medial, Patellofemoral Compartments• Removal or repair of a torn meniscus (cartilage)• Ligament reconstruction (ACL)• Removal of loose debris

– Loose body, joint mice

• Trimming damaged cartilage

Knee ArthroplastyKnee Arthroplasty

• Total– Femur and tibia ends replaced

• Partial– Only one end replaced

• Computer-assisted

• Minimally-invasive

• May need to be repeated– Patient will be shorter

OsteoporosisOsteoporosis

• Calcium– Carbonate– Carbonate w/sodium

fluoride• Phosphate• Vitamin D• HRT (estrogen)• Bisphosphonate

– Fosamax– Actonel

• Calcitonin (nasal)• Parathyroid hormone

• Exercise to slow– Avoid in later stages

• Analgesics• Muscle relaxants

Osteoarthritis TreatmentsOsteoarthritis Treatments

• Osteoarthritis– Tx goal – reduce inflammation– Nutrition

• Fish oil• Glucosamine / Chondroitin

• Drug tx– Analgesics– Muscle relaxants– NSAIDs– Injections of steroids

Osteoarthritis TreatmentsOsteoarthritis Treatments

• PT– ROM– Heat/Cold– Massage

• Support– Wraps, splints– Cane, walker– Braces, crutches

• Rest

– Surgery for severe cases• Arthroplasty

–Hip, Knee common

–Ankle, wrist, elbow, shoulder

• Arthrodesis–Vertebrae–Cervical, Lumbar

Rheumatoid Arthritis TxRheumatoid Arthritis Tx• Early, aggressive tx to prevent deformity now standard• NSAIDs/Analgesics (oldest tx)• Glucocorticoids or Prednisone

– Low doses slow joint damage • Disease Modifying Antirheumatic Drugs (DMARDs)

– Used w/ NSAIDs and/or prednisone, slows joint destruction• methotrexate, injectable/oral gold, penicillamine,

azathioprine, chloroquine, hydroxychloroquine, sulfasalazine

• Protein-A Immunoadsorption Therapy– not drug, filters blood, removes antibodies and

immune complexes that promote inflammation

RA TxRA Tx

• Biologic Response Modifiers – Directly modify immune system by inhibiting

proteins called cytokines• abatacept, etanercept, infliximab, adaliumumab

and anakinra

• Combination tx – more aggressive– Methotraxate plus BRMs

• lefluonomide (Arava), etanercept (Enbrel), adalimumab (Humira) and infliximab (Remicade).

RA SurgeryRA Surgery• Synovectomy

– One/ two joints affected more severely– Reduces inflammatory tissue – May result in less swelling/pain; slows/prevents further

damage• Arthroscopic Surgery

– Surgeon views damage, then – Bx, Remove loose cartilage, Repair tears, Smooth

rough surfaces, Remove synovial tissue– Knee and shoulder most commonly

• Osteotomy– Increase stability, Redistributes weight on joint. – Not often used for RA

RA SurgeryRA Surgery

• Joint Replacement Surgery or Arthroplasty– Prevents going into wheelchair– Removal of joint– Resurfacing and relining ends of bones– Replacing joint w/ man-made component– Usually recommended for people 50+ or w/ severe

disease progression– Typically, new joint lasts 20 to 30 years

• Arthrodesis or fusion– Fuses two bones together– Limits movement, Decreases pain– Increases stability of ankles, wrists, fingers, toes, and

spine

Rickets/OsteomalaciaRickets/Osteomalacia

• Tx underlying cause if 2ndary• Vitamin D• Calcium• Phosphate• Special bracing to position body

appropriately as the bones grow • Surgery for severe skeletal deformities

– Bone removed and external fixation devices

Carpal TunnelCarpal Tunnel

• Outpatient procedure

• Open– Longer healing time

• Endoscopic– More risk of nerve injury– Not for DM pts

– ORLive video (listed in Resources)

Bone Cancer DxBone Cancer Dx

• X-ray• Bx, needle and/or open• CT scan w/o and w/ contrast• MRI (contrast)• Bone scan• PET scan• Blood tests

– alkaline phosphatase

Bone Cancer StagingBone Cancer Staging

• Basis for tx decisions• Common elements in

most systems– Location of primary tumor– Tumor size and # – Lymph node involvement – Cell type and tumor grade– Metastasis

• TNM– T = tumor extent– N = spread to lymph nodes– M = metastasis– # = size/extent of tumor and

spread (after each letter)• Osteosarcoma (rare)

– Enneking staging system (3 stages)

• Grade, size, spread• I to III (A or B)

– AJCC system (4 stages)• I to IV

TNM Ca StagingTNM Ca Staging• Primary Tumor (T)

– TX can’t evaluate– T0 No evidence– Tis Carcinoma in situ – T1, T2, T3, T4 Size and/or extent of tumor

• Regional Lymph Nodes (N)– NX can’t evaluate – N0 No regional lymph node involvement– N1, N2, N3 Involvement of regional lymph nodes

• Distant Metastasis (M)– MX can’t evaluate– M0 No distant metastasis– M1 Distant metastasis

TNM Ca StagingTNM Ca StagingStage Definition

Stage 0 Carcinoma in situ (early cancer that is present only in the layer of cells in which it began)

Stages I – III Higher numbers indicate more extensive disease

Stage IV Cancer has spread to another organ

Source: http://www.cancer.gov/cancertopics/factsheet/Detection/staging

Different combinations of TNM levels = different stages for different CAs

Bone Cancer TxBone Cancer Tx

• Surgery– Remove tumor– Limb-sparing,

reconstructive surgery

– Amputation

• Chemotherapy– Combination of drugs– NOTchondrosarcoma

• Radiation therapy– Chondrosarcoma,

ESFTs– Combined with

surgery

• Cryosurgery – Liquid nitrogen

• Clinical trials

Marfan SyndromeMarfan Syndrome

• Scoliosis/Kyphosis– Curve > 20°, <40°

• Brace to prevent worsening (23 hours/day)• TLSO thoracolumbosacral orthosis • Boston, Wilmington, Providence, Charleston

– Curve = 40 ° to 50 °• Inserting metal rods and/or fusing spine• Posterior/Anterior approach

Marfan Syndrome (Chest)Marfan Syndrome (Chest)

• Open surgery - Incision across chest front– Deformed cartilage

removed, rib lining remains

– Breastbone cut and moved aside

– Rib/metal strut keeps sternum in normal position

– Metal struts removed in 6 mos via small cut under the arm (Outpt)

• Closed - No cartilage/bone removed– Two small incisions, one

under each arm– Curved steel bar inserted

thru incisions, placed under sternum, guided by horacoscope

– Special instrument rotates the bar/lifts sternum

– Bar left in place for 2 years +

Pectus excavatum - Funnel chest - Chest sinks in

Marfan SyndromeMarfan Syndrome

• Pectus carinatum– Pigeon breast -Chest sticks out– Brace– Surgery

• Removal of affected cartilages bilaterally• Excess cartilage over sternum removed• Reverse wedge osteotomy of sternum • Bracing, compression system

Slipped Disc/SciaticaSlipped Disc/Sciatica• Conservative tx

– Hot/cold packs– Muscle relaxants/analgesics– Epidural injections– PT

• Surgical tx– Percutaneous diskectomy– Diskectomy– Micro-diskectomy– Removal w/laminectomy w/ fusion of

vertebrae

Percutaneous discectomy Percutaneous discectomy

• Usually Outpt procedure

• Several percutaneous procedures – All involve inserting small instruments between

vertebrae and into middle of disc

• Fluoroscopy is used to guide instruments

• Remove disc tissue by – Cutting– Aspirating the center of the disc– Using lasers to burn or evaporate the disc

http://66.132.168.42/images/lumbar.gif

DiskectomyDiskectomyw/Laser Ablationw/Laser Ablation

• Minimally invasive

• Still investigative stage, insurance may not cover

Micro-diskectomyMicro-diskectomy

• Microdiscectomy uses microscope – Smaller incision, less damage to surrounding

tissue – Removes the portion of the disc protruding

into the spinal canal – Disc space may also be explored, any loose

fragments removed– Usually done Inpt using general anesthesia– Can be done in an outpatient surgical center

Minimally-invasive arthroplastyMinimally-invasive arthroplasty

• Alternative to spinal fusion

• Replace degenerated disc nucleus– Artificial disc prostheses – Total or partial (entire disc or just nucleus)

Discectomy w/ laminectomy w/ Discectomy w/ laminectomy w/ fusion of vertebraefusion of vertebrae

• DX – spondylolisthesis, spinal stenosis, degenerative disc disease

• Open procedure (posterior approach)

• Removes large parts of lamina and spinous processes

• 3-7 days in hospital

• Fusion may also be done to stabilize spine

• Fusion = Arthrodesis = artificial ankylosis

Break TimeBreak Time