Therapeutic, Right L4-5, L5-S1 and S1 Trans-Foraminal Epidural/Selective Nerve Root Steroid Injection - 4

DATE:  April 01, 2009

Patient:  XXXXXXXXX

DOB: XXXXXXXXX

Physician/NP/PA: XXXXXXXXX, M.D.

HISTORY:  Patient’s interval history intake updates documented in EMR, please refer to.

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 spinal stenosis/radiculopathy/lumbar degenerative joint and disc disease.

PROCEDURE:

Therapeutic, right L4-5, L5-S1 and S1 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 right L4-5 and L5-S1 foramen.  Fluoro imager rotated to AP and adjusted cephalo-caudad to superimpose anterior and posterior S1 foramina and superior-lateral aspect of foramen targeted and marked.  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 25G 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 right L4-5 and L5-S1 foramen.  S1 needle tip positioned posterior to vestigial S1-2 disc area stopping short of S1 nerve root contact. Patient monitored for negative sharp or acute radicular symptoms down the corresponding extremity.

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 all levels.

After achieving appropriate needle tip localization and checking for negative aspiration for heme and CSF, 4 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.