JOURNAL SQUARE SURGICAL CENTER LLC

550 Newark Ave, 5th Flr. Jersey City, NJ 07306

Tel (201) 795-0205

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OPERATIVE REPORT

Patient Name:Dominguez, Maria

Date of Service:08/22/2012

Location:Journal Square Surgical Center, Jersey City, NJ.

PREOPERATIVE DIAGNOSIS:Lumbar radiculopathy.

POSTOPERATIVE DIAGNOSIS:Lumbar radiculopathy.

PROCEDURE:Left-sided L5-S1 interlaminar epidural steroid

injection.

SURGEON:En-Chia James Liu, M.D.

ANESTHESIOLOGIST:Athanasios Scinas, M.D.

ANESTHESIA:Monitored anesthesia care.

SPECIMENS:None.

COMPLICATIONS:None.

BRIEF HISTORY AND INDICATIONS:

PROCEDURE IN DETAIL:

After re-discussion of the procedure with the patient including its risks, benefits, alternatives, and outcome data and possibility of no effect or increased pain, the patient consented to the procedure verbally and in writing. The patient denies any history of bleeding tendencies or recent infections, and then decision was made to proceed to the operating room.

The patient was placed on the fluoroscopy table in a prone position with one pillow underneath her abdomen. Her back was prepped and draped in the usual sterile fashion and sterile technique was adhered to during the entire procedure. The L5-S1 interlaminar space was first identified in the anterior and posterior view. Slight angulation towards to the feet was obtained to maximize this opening. The skin overlying the top of the S1 lamina was infiltrated with 1% lidocaine using a 25-gauge needle. After which a 20-gauge Tuohy needle was slightly advanced under loss of resistance technique until the epidural space was reached. Isovue contrast 2 cc was injected at this point show good epidural without intrathecal or vascular involvement. At this point, 3 cc of 0.25% Marcaine along with 80 mg of Depo-Medrol were injected. The needle was then removed and the patient's back was cleaned and dried, and a Band-Aid was applied.

The patient was doing well in the recovery area without any signs of CNS toxicities or any neurological deficits. She was able to ambulate without any difficulties. She was instructed to followup in the office in approximately two weeks for discussion regarding her response to this procedure. She has also been advised to contact the office immediately if there are any signs of infection or bleeding.

______

En-Chia James Liu, M.D.

DICTATED NOT READ

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Dominguez, Maria

August 22, 2012