Bilateral L3/4, L4/5, and L5/S1 Facet/Zygapophysial Joint Injection/Block with Fluoroscopy

DATE:  August 25, 2009

Patient:  XXXXXXXX

DOB:  XXXXXXXX

Physician/NP/PA:  XXXXXXXX, M.D.

HISTORY:  Patient is a 49-year-old female with known chronic refractory neck and low back pain.  At the present time, she is here for obtaining diagnostic facet joint injection block/interventional management for her low back pain.  She relates some additional pain discomfort in her bilateral hip greater trochanteric area.

Interval history intake updates completed, reviewed, and documented in EMR.

The following interventional procedure was carried out at Pain Clinic fluoroscopy suite after discussing risks, benefits, alternatives and complications to procedure.

PROCEDURE:

Bilateral L3/4, L4/5, and L5/S1 facet/zygapophysial joint injection/block with fluoroscopy.

PRE & POST PROCEDURE DIAGNOSIS:

Lumbosacral spondylosis/lumbar facet syndrome/chronic refractory low back pain.

Relevant pre-procedure assessment carried out.  Integument corresponding to area examined negative for any active infection. Vitals’ monitored and patient confirmed stable prior to proceeding with procedure. Patient positioned prone, vertebrae squared, oblique or Scottie dog view obtained, skin marked corresponding to lower pole of above facet joints.  Area swabbed with Betadine and sterile draped.  25G Quincke point spinal needles introduced and advanced to above facet joints down the barrel. Intraarticular placement achieved with feel of needle entry.  Small volume of Isoview-200, 0.25ml injected to additionally confirm intraarticular-intracapsular localization of contrast.  Confirming negative aspiration for heme 10 mg of Kenalog with 0.5 ml of 0.5% Marcaine injected into each facet joint.  Needle withdrawn, hemostasis confirmed.

Patient tolerated procedure well.  No complications encountered, no blood loss assessed.  Stable clinical condition confirmed post procedure.  Safety with ambulation/mobility assessed prior to discharge.  Post-procedure care and discharge instructions reviewed and a written copy given to patient.

Note: Additional history intake, interval history updates, procedure specific informed consent, pre and post-procedure assessment, post-procedure care and discharge instructions documented in patient’s chart, please refer to.

“Procedure Concordant Pain Relief Report Form” initiated and patient instructed to monitor and mark degree of pain relief on a numeric pain scale ranging from 0 – 10 over the next 24 hours.

If patient obtains significant relief of usual back pain with above intervention will follow‑up with repeat facet block to evaluate candidacy for radiofrequency ablation of the same joints.

Sincerely,

___________________________

XXXXXXXX, M.D.