Radiofrequency Ablation/Facet Rhizotomy of Right L3/4, L4/5, and L5/S1 Facets

DATE:  April 27, 2009

Patient:  XXXXXXXXX

DOB:  XXXXXXXXX

Physician/NP/PA: XXXXXXXXX, M.D.

HISTORY:  Patient with chronic low back pain relates persistent pain on the right side with significant pain relief obtained on his left side.

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

PROCEDURE:  Radiofrequency ablation/facet rhizotomy of right L3/4, L4/5, and L5/S1 facets.  Ablation done for medial branches of right L2, L3, L4, L5, and S1 with fluoroscopy guidance.

PRE & POST PROCEDURE DIAGNOSIS:  Lumbosacral spondylosis/lumbar degenerative joint and disc disease/chronic refractory low back pain – 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 and medial branches dorsal primary rami marked on the right side with AP and ipsilateral oblique imaging of fluoro as had been done on his opposite left side.  Area prepped with Betadine and draped sterile.  Local anesthesia obtained with 30-gauge one-inch needle and 2% buffered Xylocaine with epi.  Radiofrequency carried out with 22-gauge 10 cm radiofrequency cannula with 10 mm active tip with impedance reading between 200 and 400 confirmed at all sites prior to carrying out positive localized sensory and motor testing and needle positioned to eliminate any distal radiation of symptoms.  Ablation carried out at settings of 80°C for 60 seconds repeated twice at each site 10 mg of Kenalog instilled at each site post-procedure.  Hemostasis confirmed at all sites post 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.

Patient scheduled to follow up in one month’s time post-procedure to monitor progress and improvement.

Sincerely,

___________________________

XXXXXXXXX, M.D.