DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Lumbar facet syndrome.
2. Lumbar degenerative disk disease.
3. Lumbar radiculopathy.
POSTOPERATIVE DIAGNOSES:
1. Lumbar facet syndrome.
2. Lumbar degenerative disk disease.
3. Lumbar radiculopathy.
PROCEDURE PERFORMED: Lumbar epidural steroid injection of the right L3-4, L4-5, and L5-S1 medial branch nerves with fluoroscopic-guided needle placement.
SURGEON: John Doe, MD
DESCRIPTION OF PROCEDURE: After signing informed consent, the patient was brought to the operating room and placed in prone position on the operating room table. The lower back was prepped and draped in sterile fashion. The right sacral ala was identified with an AP fluoroscopic view. A 3-1/2-inch Quincke spinal needle was inserted until the tip made bony contact at the superior aspect of the sacral ala on the right. Aspiration was negative for blood or CSF. A mixture of 10 mg of Depo-Medrol was injected at this site with 1 mL of 0.5% bupivacaine and 1 mL of 2% lidocaine. This was a 1:1 mixture. With an oblique angulation of fluoroscopy, the L4-5 and L3-4 eye of the Scottie dogs were identified corresponding with the medial branch nerve location of L3-4 and L4-5. Following this, 3-1/2-inch Quincke spinal needle was inserted, gun barrel fashion, until it made bony contact at the eye of the Scottie dog. This was for the L4-5, and again a separate needle was placed at the L3-4 eye of the Scottie dog using the same technique and fluoroscopy. Aspiration was negative for blood or CSF. Same mixture of medication was injected at each site. Needles were removed. Sterile bandage was placed. The patient was brought to the recovery area and discharged home that day.
Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Sciatica.
POSTOPERATIVE DIAGNOSIS: Sciatica.
SURGEON: John Doe, MD
ANESTHESIA: Local anesthetic lidocaine 1% plain with 1 mL sodium bicarbonate, total volume 4 mL.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
ESTIMATED BLOOD LOSS: None.
INJECTABLES: Preservative-free normal saline solution and Depo-Medrol 40 mg/mL single dose, total of 80 mg plus 0.0625% bupivacaine preservative-free.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: Risks/benefits of the procedure were discussed with the patient and the patient understands. The risks include the possibility of infection, bleeding, nerve damage, failure of pain relief, transient increase in pain, inadvertent intravascular injection, spinal blockade, dural puncture, meningitis, or arachnoiditis. The n.p.o. status was confirmed and consent form was signed.
The patient was placed in a prone position on the procedure table, and a sterile lumbar prep and drape performed using sterile technique. A skin wheal was placed, and a 20-gauge Tuohy needle was atraumatically passed under direct fluoroscopic guidance in the L5-S1 interspace. Placement was confirmed with 3 mL Isovue-300 contrast and negative aspiration of CSF. A total volume of 6 mL of injectate was administered, and the needle removed. No paresthesias during the procedure were noted. The patient tolerated the procedure well and was transported to the postprocedure recovery area in stable condition. A postoperative assessment was performed. The patient showed no signs of any sensory or motor deficits that were not present before the procedure.
Postprocedure instructions were given to the patient. The patient will be seen in the office in two weeks.
