0ST40ZZ
Resection Lumbosacral Disc to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | S Lower Joints |
| Operation | T Resection |
| Body Part | 4 Lumbosacral Disc |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Cutting out or off, without replacement, all of a body part
Procedure Overview
Resection in the lower joints means surgically removing an entire joint or joint structure without replacing it with any device. This is less common than joint replacement, typically reserved for severe infection that has destroyed a joint, a tumor requiring removal of the joint surfaces, or a salvage option after a failed implant cannot be replaced right away. A well-known example is resection arthroplasty of the hip, sometimes called a Girdlestone procedure, where the femoral head is removed and the space fills with scar tissue.
Because no artificial joint is inserted, patients typically have a shortened limb and altered mechanics, and mobility aids or later reconstruction may follow. This trade-off is usually accepted specifically to clear infection or malignant tissue threatening the limb.
Anatomy & Axis Detail
Lumbosacral Disc
The lumbosacral disc lies at the L5-S1 level, the transition point between the mobile lumbar spine and the fixed sacrum, and experiences some of the highest mechanical stresses in the vertebral column. Resection here means removing the entire disc, typically to prepare the L5-S1 interspace for interbody fusion when degeneration, spondylolisthesis, or instability at this junctional level requires eliminating the disc as a mobile segment. The anatomy at this level is complicated by the lumbosacral angle and the proximity of the iliac vessels and sacral nerve roots, which can influence the surgical approach chosen to reach the disc space. Because L5-S1 is a frequent site of degenerative change, complete disc resection at this level is almost always followed by graft placement and instrumented fixation to restore segmental support.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Coding & Documentation
A coder should look for documentation that the joint or a defined structure was entirely removed and nothing was implanted in its place; if a spacer or prosthesis went in during the same operation, the case likely calls for Replacement or a combination of codes instead of Resection alone. Infection control, pathology reports for malignancy, and prior failed hardware are common clinical justifications. The most frequent error is coding Resection when an antibiotic cement spacer was actually placed, since a spacer typically reclassifies the procedure as Replacement.