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

DATE:  August 26, 2009

Patient:  XXXXXXXXXX

DOB:  XXXXXXXXXX

Physician/NP/PA:  XXXXXXXXXX, M.D.

HISTORY:  Patient followed up two days prior for same problem and scheduled for today’s intervention, please refer to additional documentation in EMR for today’s encounter.

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

PROCEDURE:

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

2.      Right sacroiliac joint injection.

PRE & POST PROCEDURE DIAGNOSIS:

Lumbosacral spondylosis/chronic refractory low back pain/sacroiliitis.

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  Needle withdrawn, hemostasis confirmed.

A 25-gauge Quincke point needle inserted into right sacroiliac joint radiocontrast dye injected and localization of contrast in SI joint intra-articular space confirmed.

Subsequently, 20 mg of Kenalog with 0.5 ml of 0.5% Marcaine instilled.  Needle withdrawn post injection.  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.

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.

Sincerely,

___________________________

XXXXXXXXXX, M.D.