Left L3/4, L4/5, and L5/S1 Facet Rhizotomy with Radiofrequency Ablation of Left L2, L3, L4 Medial Branch, L5 Dorsal Primary Rami, and S1 Facet Branch

Left L3/4, L4/5, and L5/S1 Facet Rhizotomy with Radiofrequency Ablation of Left L2, L3, L4 Medial Branch, L5 Dorsal Primary Rami, and S1 Facet Branch

DATE:  April 13, 2011

Patient:  XXXXXXXX

DOB: XXXXXXXX

Physician: XXXXXXXX, M.D.

HISTORY:  He relates persistent severe back pain.  Examination negative for radiculopathy, sciatica, or myelopathy.

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

PROCEDURE:  Left L3/4, L4/5, and L5/S1 facet rhizotomy with radiofrequency ablation of left L2, L3, L4 medial branch, L5 dorsal primary rami, and S1 facet branch.

PRE & POST PROCEDURE DIAGNOSIS:  Lumbosacral spondylosis/low back pain/lumbar facet syndrome.

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 on fluoroscopy table, AP and ipsilateral oblique views of lumbosacral spine carried out and skin marked for above nerves.  Area prepped with Betadine and draped sterile.  Local anesthesia obtained with 30-gauge one-inch needle and 2% buffered Xylocaine with epi.  Subsequently, 10 cm radiofrequency cannula with 10 mm active tip inserted, 22-gauge.  Needle localized to lie at the angle of superior articular process and transverse process with distal bony resistance.  Impedance reading between 200 and 400 confirmed at all sites prior to carrying out sensory and motor testing.  Positive sensory testing at less than 1 to 2 mV confirmed at all sites with positive motor testing for localized muscle taping and absence of distal symptoms in extremity.  Needle tip for L5 and S1 localized at superior articular process, sacral ala angle, and superolateral corner of S1 foramen.

Subsequently, local anesthesia obtained with 0.5 ml to 1 ml of 0.5% Marcaine and radiofrequency ablation done at setting of 60 seconds at 80° repeated twice at each site with slight needle repositioning.  Negative complications monitored at all sites.  Needles withdrawn after instillation of 10 mg of Kenalog post-ablation.

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.

Patient to be scheduled for similar intervention the opposite side in two weeks’ time.

Sincerely,

___________________________

XXXXXXXX, M.D.