Therapeutic, Left L3-4 and L4-5 Trans-foraminal Epidural/Selective Nerve Root Steroid Injection - 2

DATE:  April 13, 2009

Patient:  XXXXXXXXX

DOB: XXXXXXXXX

Physician/NP/PA: XXXXXXXXX, M.D.

HISTORY:  Patient evaluated one-day prior, please refer to this assessment.  She relates no significant interval changes.

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

PRE & POST PROCEDURE DIAGNOSIS:  Low back pain/sciatica.

PROCEDURE:  Therapeutic, left L3-4 and L4-5 trans-foraminal epidural/selective nerve root steroid injection.

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, oblique or Scottie dog view of lumbar spine obtained, foraminal opening maximized and SAP visualized. Skin marked targeting the infra-pedicular aspect or superior-lateral-anterior aspect of left L3-4 and L4-5 foramina.  Lumbo-Sacral area prepped with Betadine and sterile draped.  Skin anesthetized with 30G, 1” needle and 1-2ml of 2% buffered lidocaine with epi.  Subsequently 22G Whitacre needles introduced and advanced down the barrel technique with intermittent fluoro.  Lateral imaging obtained, depth of needle insertion controlled to reach placement in upper pole of foramen.  Stylet removed and negative aspiration for heme and CSF confirmed.  1 to 2 ml of Isoveiw-200 injected and spread in nerve root/foraminal epidural space noted.  Imager rotated AP and contrast spread centrally and proximally along medial aspect of pedicle confirmed at each level.

After achieving appropriate needle tip localization and checking for negative aspiration for heme and CSF, 6 mg of Celestone Soluspan (1:1 Betamethasone acetate and phosphate) with 0.5 ml of 1% PF Lidocaine and 0.5 ml of 0.25% PF Bupivicaine instilled at each of the nerve roots.

Patient monitored for negative sharp or acute radicular symptoms down the corresponding extremity.  Needle withdrawn, hemostasis confirmed. Patient tolerated procedure well.  No complications encountered, no CSF leak or 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 instructed to call Pain Clinic and follow up as needed.

Sincerely,

___________________________

XXXXXXXXX, M.D.