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

DATE:  April 06, 2009

Patient:  XXXXXXXXX

DOB: XXXXXXXXX

Physician/NP/PA: XXXXXXXXX, M.D.

HISTORY:  Patient seen one-day prior, please refer to this assessment note scheduled for facet joint intervention today.

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

PROCEDURE:

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

PRE & POST PROCEDURE DIAGNOSIS:

Low back pain/lumbosacral spondylosis – lumbar facet arthropathy, lumbar spinal stenosis.

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 20 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  Needle withdrawn, hemostasis confirmed.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 she obtains pain relief from above intervention injection repeat intervention can be considered after four to six weeks, patient to call us as needed.

Sincerely,

___________________________

XXXXXXXXX, M.D.