REFERRING PHYSICIAN:  John Doe, MD

PROCEDURES PERFORMED:

1.  Lumbar epidural steroid injection.

2.  Fluoroscopy.

3.  Epidurography.

DESCRIPTION OF PROCEDURE:  The patient was placed prone on the x-ray table with pillows under her pelvis for pain management procedure. The lumbar area was cleansed with alcohol and Betadine. Sterile drape was applied to her lumbar area. Fluoroscopy was used to identify the L5-S1 interspace. Lidocaine 1% with epinephrine was used to anesthetize the skin and the interspinous ligament at L5-S1 interspace.

Under fluoroscopic guidance, a 17-gauge Tuohy needle was advanced into the epidural space to the right of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage. Two mL of Isovue 300 was injected through the needle. This revealed good flow of contrast in the epidural space to the right of the midline. This was confirmed with lateral fluoroscopy. I then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken.

The patient was taken to the recovery room where she was observed for about 30 minutes before being discharged.

Pain Management Procedure Sample Report #2

DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURES PERFORMED:

1.  Caudal steroid injection.

2.  Fluoroscopy.

3.  Epidurography.

4.  IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was placed prone on the x-ray table with pillows under her pelvis for pain management procedure. Her sacral area was cleansed with alcohol and Betadine, and sterile drape was applied to her sacral area. Lidocaine 1.5% with epinephrine was used to anesthetize the skin and subcutaneous tissue at the sacral hiatus.

Under fluoroscopic guidance, a 17-gauge Tuohy needle was advanced into her caudal space with the point of the needle to the left of the midline. The caudal space was encountered without any problems, complications, CSF or heme drainage. Two mL of Isovue M 300 was injected through the needle. This revealed good flow of contrast as far as the L5-S1 interspace. I then threaded a catheter for a distance of 15 cm and injected 50 mL of Isovue M. This revealed flow of contrast into a left nerve root. The catheter was therefore withdrawn and repositioned and 50 mL of Isovue M was injected. This revealed good flow of contrast and to the left of midline. I then proceeded to inject a 5 mL solution containing 80 mg of Depo-Medrol and 1.5 mL of Isovue M 300. The catheter was cleared and removed and came out intact. The needle was cleared and removed. Permanent films were taken.

The patient was returned to the recovery room where she was observed and monitored for approximately 1 hour before being discharged.

PREOPERATIVE DIAGNOSES: Postlaminectomy syndrome, lumbar facet syndrome, lumbar radiculopathy.

POSTOPERATIVE DIAGNOSES: Postlaminectomy syndrome, lumbar facet syndrome, lumbar radiculopathy.

PROCEDURE PERFORMED: Right lumbar medial branch block of L3-4, L4-5, and L5-S1.

DESCRIPTION OF PROCEDURE: After signing informed consent, the patient was brought to the operating room for right lumbar medial branch block of L3-4, L4-5, and L5-S1 and placed in a prone position on the operating room table. The lower back was prepped and draped in a sterile fashion on the right side. The right sacral ala was identified with an AP fluoroscopic view. A 25-gauge, 3-1/2 inch Quincke spinal needle was inserted, gun barrel fashion, and directed downward until the tip made bony contact at the sacral ala. Aspiration was negative for blood or CSF. A mixture of 1 mL of 0.5% bupivacaine and 10 mg of Depo-Medrol was injected at this site. The needle was removed. Attention was turned to the L4-5 medial branch nerve location located at the proximal SAP and eye of the scotty dog. The same 3-1/2 inch Quincke spinal needle was inserted, gun barrel fashion, and directed downward until the tip made bony contact at the eye of the scotty dog. Aspiration was negative for blood or CSF. The same mixture of medication was injected at this site. Attention was turned to the L3-4 medial branch nerve site and the exact same technique and medication was used to perform the medial branch nerve block for the L3-4. All needles were removed at the end of the procedure. Sterile bandage was placed. The patient was brought to the recovery area and discharged home that day.

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Cervical facet syndrome, cervical radiculopathy.

POSTOPERATIVE DIAGNOSIS: Cervical facet syndrome, cervical radiculopathy.

PROCEDURE PERFORMED: Right cervical medial branch block of C4-5, C5-6, and C6-7.

DESCRIPTION OF PROCEDURE: After signing informed consent, the patient was brought to the fluoroscopy suite for right cervical medial branch block of C4-5, C5-6, and C6-7 and placed in a prone position on the fluoroscopy table. The cervical area was prepped and draped in a sterile fashion. Using AP fluoroscopic guidance, the cervical transverse process was identified corresponding with the right C4-5, C5-C6, and C6-7. At transverse process C5, the Quincke spinal needle was placed and advanced until the tip made bony contact to the lateral aspect. Aspiration was negative for blood or CSF. A mixture of 2 mg of Celestone plus 0.5 mL of 0.5% bupivacaine with 2% lidocaine mixed 1:1, both preservative free, was injected at this location. The needle was withdrawn slightly and redirected to cephalad until it made bony contact at the transverse process of C4 and exact same medication was injected following negative aspiration for blood or CSF. The needle was withdrawn again slightly and then redirected caudally until the tip made bony contact to C5-6 medial branch nerve location. Again, the same medication was injected following a negative aspiration for blood or CSF. Needle was removed. Sterile bandage was placed. The patient did note some improvement of range of motion immediately following the procedure. She was brought to the recovery area and discharged home without incident.

PREOPERATIVE DIAGNOSIS: Thoracolumbar radiculitis.

POSTOPERATIVE DIAGNOSIS: Thoracolumbar radiculitis.

PROCEDURES PERFORMED:
1.  Lumbar epidural steroid injection, left T12-L1 transforaminal space.
2.  Lumbar epidural steroid injection, right T12-L1 transforaminal space.
3.  Epidurography.
4.  Intravenous sedation.
5.  Fluoroscopy for needle placement and aspiration.
6.  Constant monitoring including pulse, pulse oximetry, electrocardiogram, blood pressure, and verbal monitoring.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female suffering long-term with historic and physical exam findings consistent with the above-described diagnosis. She requests the above-described procedure to help facilitate her physical therapy and recovery from this pain syndrome. She understands that the risks include, but are not limited to, bleeding, infection, nerve damage, pain, possible blood clots, disability, death, worsened pain, no relief of pain, need for further procedures, need for hospitalization, spinal headache, need for bedrest. Multiple questions were asked and answered in detail. Informed consent was obtained.

DESCRIPTION OF PROCEDURE:  After consent was obtained, a detailed allergy history was carried out and found to be noncontributory. The patient was administered IV access, transported to the fluoroscopic suite, laid prone on the fluoroscopic table, monitoring devices applied, and IV sedation administered. The lumbar spine was sterilely prepped and draped in the normal fashion. After satisfactory anesthesia was demonstrated, the procedure was commenced.

A 22-gauge spinal needle was passed through the skin and deep tissue down to the level of the left-sided T12-L1 transforaminal space. Multiple fluoroscopic images were used to direct the needle. Aspiration was carried out to be certain the needle was not intradural or intravascular. Then, 1 mL contrast was infiltrated. Target localization was noted with appropriate spread of contrast. In a separate syringe, 3 mL of Depo-Medrol and 2 mL of 0.5% Marcaine was drawn up. Half of this mixture was infiltrated. Dye washout was noted. Mild reproduction of symptoms was noted, which resolved spontaneously.

Attention was then directed towards the right-sided T12-L1 transforaminal space. Multiple fluoroscopic images were used to direct a 22-gauge needle. Aspiration was negative. Contrast was infiltrated. Target localization was noted with appropriate spread of contrast. The remainder of the previously drawn up mixture was infiltrated. Dye washout was noted. Mild reproduction of symptoms was noted, which resolved spontaneously.

Following the procedure, there was no sign of anaphylactic or anaphylactoid reaction. The patient was given detailed postinjection instructions and encouraged to monitor symptoms and call with any questions or concerns.

REFERRING PHYSICIAN: John Doe, MD

CHIEF COMPLAINT: Left-sided chest wall pain, rib pain.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of significant left-sided rib cage pain and chest wall pain since the past one year. She does not recall any specific trauma in that time. Basically, the patient had surgery in that region that involved partial removal of her rib, and the patient explained that it was a benign tumor in the area; this was almost 16 years ago. Approximately two years ago, the patient also had trauma in the same area that resulted in two or three broken ribs in that area. Apparently, she has had some discomfort off and on but not significant or severe. The pain is described as a burning, numbness, discomfort that comes out of the side. It could be with the patient resting or ambulating or with or without physical activity. The pain, when it comes, can reach a level of 10 on a scale of 0-10. The patient states that, so far, all the studies have been negative. The patient on this admission had bone scans, x-rays, and all types of laboratory data, and all have come in negative for any pathology in that area. The patient has been receiving Percocet, Celebrex. She denies any bowel or bladder dysfunction. The patient denies any history of herpes zoster or shingles from the past. The chronic pain service has been consulted for evaluation.

PAST MEDICAL HISTORY: Significant for arrhythmias and chest wall pain. Otherwise, unremarkable.

PAST SURGICAL HISTORY: Hysterectomy and lumbar surgery in the past and also removal of a tumor in the left chest wall area.

MEDICATIONS: Reviewed.

ALLERGIES: NKDA.

SOCIAL HISTORY: The patient lives with her son. She denies tobacco or alcohol use.

FAMILY HISTORY: Negative for chronic pain syndrome.

REVIEW OF SYSTEMS: Positive for chest wall pain. Otherwise negative as per the patient information on admission to Florida Hospital/Celebration.

PHYSICAL EXAMINATION:
GENERAL: The patient is a (XX)-year-old female lying in bed supine. She is awake, alert, and oriented. She appears in no acute distress.
HEENT: Normocephalic. Face is symmetric.
NECK: Good cervical mobility.
LUNGS: Clear.
HEART: Regular rhythm.
CHEST WALL: Normal symmetric excursions. Tenderness to palpation in the left-sided lower rib cage area. No deformity observed. No skin lesions observed but certainly the pain follows a pattern approximately from the 7-8th rib to the 10-11th rib on the left. There is a well-healed scar from previous surgery in the left rib cage area.
ABDOMEN: Soft.
EXTREMITIES: Lower Extremities: Negative for sensory or motor deficit. Gait: Able to ambulate without assistance.
PSYCHIATRIC: The patient denies any history of depression or anxiety.
NEUROLOGIC: Nonfocal.
SKIN: Unremarkable.

RADIOLOGICAL DATA: CT of the chest basically negative, other than some alveolar filling, lungs with infiltrates. No mass observed. Bone scan negative.

LABORATORY DATA: Basically unremarkable. Sedimentation rate 26. Potassium 4.2, sodium 137, creatinine 1. White cell count 6.2 and platelets 202.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with left-sided chest wall pain that the patient describes as a burning, numbness-type discomfort. It appears to me to be a neuropathic-type pain, possible nerve entrapment versus neuroma of the intercostal nerves at that level. Taking into consideration that all the radiological data at this time has been negative at that level, the patient does not have a mass, there is no tumor, there is no bleeding, and there is no infection, the patient may benefit from consideration of a diagnostic intercostal block at that level. The patient is ready to be discharged today. The patient is comfortable on the current pain medications. We would suggest the patient be discharged and follow up as an outpatient in the pain clinic for possible intercostal nerve block.

PREOPERATIVE DIAGNOSIS:  Low back pain with radiculopathy.

POSTOPERATIVE DIAGNOSIS:  Low back pain with radiculopathy.

PROCEDURE PERFORMED:  Lumbar epidural steroid injection.

SURGEON:  John Doe, MD

COMPLICATIONS:  Spinal tap.

SPECIMENS REMOVED:  None.

DESCRIPTION OF PROCEDURE:  The patient was evaluated in the preoperative area, and the details of the procedure, risks, benefits, and complications were discussed with the patient. An MRI scan was reviewed. History and physical and consent was completed. The patient agreed for the procedure and was taken to the procedure room.

The patient was laid prone on the procedure table, and the L5-S1 epidural space was identified. The skin was cleaned with Chloraprep x2 and draped in a sterile fashion. After identification of the L5-S1 interlaminar space, a 17 gauge 3.5 inch Tuohy needle was gently introduced into the epidural space using intermittent fluoroscopy and loss of resistance technique. On reaching the epidural space, there was a sudden gush of clear fluid. The needle was immediately withdrawn and pressure was applied. The patient did not feel any headache or change in vital signs.

After making sure that the patient was comfortable and was not complaining of any related complications, the L4-L5 epidural space was identified with intermittent fluoroscopy and loss of resistance technique and a 3.5 inch needle was gently introduced after anesthetizing the skin. The space was easily identified, and confirmation of the epidural space was done by putting 1.5 mL of Isovue dye. After confirmation of the epidural space, an 8 mL solution containing 120 mg of Depo-Medrol and 0.125% Marcaine was slowly injected into the space.

The patient tolerated the procedure well, and there were no immediate complications. The patient was taken to the postoperative area and was started on IV drip of 500 mL of normal saline and was monitored for about 1-2 hours. The patient was also given coffee to drink. The patient did not complain of any headache or any numbness in the lower extremities. The patient was discharged home on the same day with the instructions to call the acute pain service in case she has worsening symptoms or severe headache. The patient understood the instructions, and she would be followed up in the clinic as arranged earlier. We would reschedule her for another LESI in the future.