DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
PREOPERATIVE DIAGNOSES:
1. Chronic low back pain
2. Lumbar radiculopathy secondary to failed back syndrome.
3. Bilateral facet arthropathy and spinal stenosis.
POSTOPERATIVE DIAGNOSES:
1. Chronic low back pain
2. Lumbar radiculopathy secondary to failed back syndrome.
3. Bilateral facet arthropathy and spinal stenosis.
OPERATION PERFORMED:
1. Bilateral facet joint injections at L3-L4, L4-L5, And L5-S1.
2. Epidural injection under fluoroscopy, L5-S1.
ANESTHESIA: Local and IV sedation.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old Asian female with a history of chronic low back pain for the past five years. She had a L4-L5 laminectomy and diskectomy four years ago secondary to a herniated disk; however, the patient continued to have low back pain and she has seen multiple physicians since. She was maintained on Vicodin on an as needed basis.
However, about three weeks ago, the patient had significant low back pain and she was admitted to the hospital, and during her admission, an MRI suggested multiple facet arthropathies and spinal stenosis. Dr. Jane Doe performed bilateral facet joint injections at multiple levels, which gave the patient some improvement and she was discharged and she was maintained on Vicodin and muscle relaxants and she is here for a second epidural steroidal injection.
She says her pain at this time is 10/10 because she has not taken any anti-inflammatories or her pain medications; therefore, an IV was started and she was already using Versed and fentanyl.
PROCEDURE #1: The patient was brought to the fluoroscopy imaging suite. She was placed supine on the imaging table. The lumbosacral area was then prepped with Betadine and was draped sterilely. Using C-arm fluoroscopy in the AP view, lumbar vertebral bodies were identified and the interspace region, L5-S1, was selected for the epidural injection. After anesthetizing the skin with 1% lidocaine, 17-gauge Tuohy needle was introduced in the epidural space using fluoroscopic guidance and also loss-of-resistance technique. Once the needle tip was in the epidural space, 2 mL of Isovue-M 200 was injected which showed the dye spreading adequately in the epidural space. This was checked in lateral view also. After negative aspiration for any blood or CSF, 120 mg of Depo-Medrol mixed with 2 mL of 0.5% Marcaine was injected.
PROCEDURE #2: Multiple facet injections. We started at the right L3-L4 after anesthetizing skin with 1% lidocaine, and 22-gauge Tuohy spinal needle was introduced into the facet joint under fluoroscopic guidance. Once the needle tip was in the joint, 0.5 mL of Isovue-M 200 was injected which showed the dye spreading adequately in the facet joint. This was followed by the injection of 40 mg of Depo-Medrol mixed with a 1 mL of 0.5% Marcaine. Similar procedures were carried out at left L3-L4, right L4-L5, left L4-L5, right paraspinal and left L5-S1. The patient tolerated the procedure well. She was monitored postoperatively for 1 hour and was discharged home in stable condition.
