Bilateral L3/4, L4/5, and L5/S1 Facet/Zygapophysial Joint Injection/Block with Fluoroscopy - 3

DATE:  April 27, 2009

Patient:  XXXXXXXXX

DOB:  XXXXXXXXX

Physician/NP/PA: XXXXXXXXX, M.D.

HISTORY:  Patient relates significant resolution of her sciatica with persistent localized low back pain with an average pain severity level of 6/10, please refer to additional interval history documentation tool 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:

Low back pain/lumbosacral spondylosis/lumbar degenerative joint and disc disease.

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 5 mg of Kenalog with 0.5 ml of 0.5% Marcaine injected into each facet joint.  Needle withdrawn, hemostasis confirmed.

Patient transiently felt some lightheadedness while receiving intervention, which resolved completely by end of procedure and was able to sit up and ambulate without any difficulties.

Post-procedure vital signs showed blood pressure on the higher side for systolic with diastolic below 100.  She was instructed to additionally follow up with her primary for this.

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.  She was to call us as needed in four weeks’ time for this.  She also may not need to hold Plavix for facet joint injection block; however, she will need to hold her Plavix for radiofrequency ablation.

Sincerely,

___________________________

XXXXXXXXX, M.D.