Radiofrequency Ablation Left L2, L3, L4 Medial Branches, L5 Dorsal Primary Rami, and S1 Facet Branch with Fluoroscopy Guidance

Radiofrequency Ablation Left L2, L3, L4 Medial Branches, L5 Dorsal Primary Rami, and S1 Facet Branch with Fluoroscopy Guidance

DATE:  April 28, 2011

Patient:  XXXXXXXX

DOB:  XXXXXXXX

Physician: XXXXXXXX, M.D.

HISTORY:  Patient relates persistent pain in the back corresponding to the left side.  Interval history intake updates obtained, reviewed, and documented.

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

PROCEDURE:  Radiofrequency ablation left L2, L3, L4 medial branches, L5 dorsal primary rami, and S1 facet branch with fluoroscopy guidance.

PRE & POST PROCEDURE DIAGNOSIS:  ______________________.

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 imaging of lumbar spine carried to mark above medial branches and dorsal primary rami at corresponding target points.  Area prepped with Betadine and draped sterile.  Local anesthesia obtained with 2% buffered lidocaine with epi and 30-gauge one-inch needle.  Subsequently, radiofrequency ablation carried out with a 10 cm 22-gauge radiofrequency cannula with 10 mm active tip at settings of 80°C for 60 seconds repeated twice at each site.  Impedance reading between 200 and 400 confirmed at all sites and positive localized sensory and motor testing with negative distal symptoms confirmed prior to all ablation.  Anesthesia carried out with 0.5 to 1 ml of 0.5% Marcaine prior to ablation.  10 mg of Kenalog instilled post ablation at each site prior to needle withdrawal.

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.

Patient to follow up at Pain Clinic in four weeks’ for reassessment.

Sincerely,

___________________________

XXXXXXXX, M.D.