Therapeutic, Left L4 and L5 Trans-Foraminal Epidural/Selective Nerve Root Steroid Injection - 1

DATE:  August 30, 2009

Patient:  XXXXXXXXX

DOB:  XXXXXXXXX

Physician/NP/PA:  XXXXXXXXX, M.D.

HISTORY:  Patient is a 74-year-old gentleman with left low back pain radiating down his left lower extremity.  Recent imaging data – MRI lumbar spine from 08/11/2009 once again reviewed.

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:  Lumbar degenerative joint and disc disease with sciatica – lumbar radiculopathy and spinal stenosis.

PROCEDURE:  Therapeutic, Left L4 and L5 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 L4 and L5 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 22 G 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 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  Needle withdrawn, hemostasis confirmed.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.

“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 scheduled to follow up in one month’s time for possible repeat intervention.

Sincerely,

___________________________

XXXXXXXXX, M.D.