RE: Marilyn Salvadori
DOS: 08/29/2016
Page 3
PATIENT:Marilyn Salvadori
MEDICAL RECORD:17418
DATE OF BIRTH:05/15/1932
DATE OF SURGERY:08/29/2016
SURGEON:Terrence M. Welsh, M.D.
OPERATION:Left-sided L4-L5 transforaminal epidural steroid injection.
ANESTHESIA:Local.
RELEVANT HISTORY: Ms. Salvadori is an84-year-old femalereferred to my office by Dr. Carney for evaluation and consultation in regards to her ongoing left-sided buttock and posterior leg pain consistent with sensory radiculitis. The patient has had this pain for six months. She did undergo an MRI which revealed evidence of severe stenosis of the L4-L5 level. She did subsequently undergo an injection by myself at the L4-L5 level which did provide a number of months of excellent pain relief. The patient recently returned with re-emergence of her symptoms and so today I will repeat that injection for additional pain relief. The patient is on Plavix. I did discuss with the patient performing this procedure while she is remaining on Plavix. The risks and benefits to this procedure, obviously she is on Plavix for specific reason, so discontinuing with that medication carries its own risk. After a careful and thoughtful discussion that the patient did wish to proceed with the procedure, knowing that she does have an increased risk of having a bleeding complication from that procedure due to the fact that she is on that medication.
PRE-PROCEDURE DIAGNOSIS: Lumbar spinal stenosis.
POST-PROCEDURE DIAGNOSIS: Lumbar spinal stenosis.
PROCEDURE PERFORMED:
- Left sided L4-L5 transforaminal epidural steroid injection.
- Fluoroscopic guidance.
INFORMED CONSENT: The risks, benefits and alternatives of the procedure were explained to the patient and written consent obtained. The patient was given the opportunity to ask questions regarding the procedure, its indications, and associated risks. The risks discussed include but are not limited to: nerve damage, neuritis, extremity weakness/numbness, treatment failure, increased pain, infection, bleeding, allergic reaction, dural puncture, headache, spinal cord injury, cardiovascular and CNS side effects with possible vascular injury,medications, any adverse reactions to sedation or any medications administered during the procedure including contrast, anesthetics and corticosteroids. The patient was informed both verbally and in writing.
PROCEDURE IN DETAIL:
TREATMENT MEDICATIONS:
- 2 ml of buffered 1% lidocaine, 15 mg of preservative free dexamethasone in divided doses and 0.25% Bupivicaine.
CONTRAST: Omnivue 300.
Treatment Needle:
1#25 gauge 3.5-inch spinal needle x2.
The patient was transferred to the procedure room and placed in a prone position with the pillow under the abdomen to reduce lumbar lordosis. Vital signs were monitored throughout the procedure. A “time-out” was performed immediately prior to the procedure to confirm correct patient, procedure and site. The procedure site is prepped and draped in usual sterile fashion with DuraPrep. The sterile technique was used throughout the procedure. Fluoroscopy is used to identify the bony landmarks at the left L4-L5 neuroforamen in the planned oblique approach. The skin over this area was anesthetized with buffered 1% lidocaine. The spinal needle was gently guided into the superior anterior neuroforamen lateral to the mid-pedicular line using intermittent fluoroscopy. Multiple fluoroscopic views were used to ensure proper needle placement. Fluoroscopy was then used to identify the bony landmarks to the left L5/S1 neuroforamen. Again the skin over this area was anesthetized with buffered 1% lidocaine. Once again the spinal needle was gently guided through the anesthetized area into the superior anterior neuroforamen lateral to the mid-pedicular line using intermittent fluoroscopy. Once again multiple fluoroscopic views were used to ensure proper needle placement. Aspiration with the syringe resulted in no blood or CSF return. An extension tube was attached to each needle to complete the remainder of the injection. Contrast was injected under direct real-time fluoroscopic observation. Correct needle placement was confirmed by production of an appropriate epidurogram and radiculogram without concurrent vascular uptake at each level. Finally after an uneventful test dose of 1 ml of 0.25% Bupivicaine, 7.5 mg of dexamethasone was injected at each level. The needles were re-styletted and withdrawn. The skin was cleansed with sterile bandage placed over the needle puncture site.
COMPLICATIONS: None.
The patient tolerated the procedure well without hemodynamic or neurologic sequela and was transferred to the recovery area for observation. The patient will be discharged home with written discharge instructions. The patient was advised to contact the on-call physician for any of the following reasons: New onset of pain, fevers, chills, night sweats, nausea, vomiting, or other constitutional change in symptoms and any upper or lower extremity weakness or changes in bowel or bladder function or any questions regarding the procedure.
SURGEON: Terrence M. Welsh, MD
ANESTHESIA: Local anesthesia only.
______
Terrence M. Welsh, MD
Date: ______
TW/mrs
Dict: 08/30/2016