DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
PREOPERATIVE DIAGNOSES:
1. Chronic low back pain with lumbar radiculopathy secondary to severe degenerative disk disease.
2. Spondylosis of lumbar spine.
3. Scoliosis.
4. Myofascial pain to the left lower back.
POSTOPERATIVE DIAGNOSES:
1. Chronic low back pain with lumbar radiculopathy secondary to severe degenerative disk disease.
2. Spondylosis of lumbar spine.
3. Scoliosis.
4. Myofascial pain to the left lower back.
PROCEDURE PERFORMED: Trigger point injection to the left gluteal muscle.
ANESTHESIA: Local.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old very pleasant female who has been suffering from rheumatoid arthritis, sarcoidosis, and chronic pain secondary to severe degenerative disk disease with spinal stenosis, scoliosis of the lumbar spine. The patient also has a sacroiliitis on the left side, and she had multiple sacroiliac joint injections along with epidural steroid injection done. The last time, the patient was seen by Dr. Jane Doe and had a second series epidural steroid injection done by her.
The patient stated that this left hip pain has been better with the sacroiliac joint injection and trigger point injection, but her pain from the lower back to the legs bilaterally, bilateral posterior thigh has been worse since after the second injection. The patient feels sharp pain in her both gluteal area and thighs, goes down to the leg with any kind of movement. The patient was started on Lyrica by her rheumatologist, but the patient had severe dizziness and sedation effect with it, so she stopped taking it. The patient also has a history of severe nausea with any kind of narcotic. She cannot tolerate any Percocet, Darvocet, or any weak narcotic either.
We examined the patient, reviewed the patient’s chart. There are three or four trigger points identified in the left gluteal area, which was marked. Straight leg raise test negative bilaterally. Bilateral hip range of motion is normal. Motor and sensory exam was unremarkable. Plan is to do a trigger point injection to the left gluteal area, since the patient has no good response to epidural injection. We think, because of her severe stenosis, she is getting more irritation with epidural steroid injection, so we will try to avoid the last epidural steroid injection. After trigger point injection, we explained to the patient to consider medical management.
DESCRIPTION OF PROCEDURE: The patient was explained about the procedure in detail, risks, benefits, and possible complications explained, and written consent was obtained. With the patient in the right lateral position, the gluteal area was prepped with alcohol and draped in a sterile fashion. Mild trigger point areas were injected with 0.5% Marcaine with Depo-Medrol.
Using 25 gauge 1-1/2 inch long needle, the trigger points were injected in fan-shaped manner, total 80 mg of Depo-Medrol with 15 mL of 0.5% Marcaine injected in the four different trigger point areas. The patient tolerated the procedure well without any complications. Sterile dressing was applied. The patient was able to walk without any problem.
The plan is to refer her for a TENS unit, will start Ultram. The patient was asked to start with the smaller dose and see whether she can tolerate it, then we will increase the dose according to her tolerance. We will start her on Cymbalta 20 mg at bedtime, and if she tolerates that, we might increase it. We also advised to continue Lidoderm patches. We will see her in four weeks for further medical management.
