Operative Report Sample:

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OPERATIVE REPORT

DATE OF OPERATION:   03/20/10
PREOPERATIVE DIAGNOSIS:
Chronic low back pain.  Lumbar discogenic pain.  Lumbar myofascial pain.    
POSTOPERATIVE DIAGNOSIS:
Chronic low back pain.  Lumbar discogenic pain.  Lumbar myofascial pain.
OPERATIVE PROCEDURE:
Right L1-L2, L2-L3, L3-L4, L4-L5, L5-S1 facet blocks under fluoroscopic guidance five levels.  Left L1-L2, L2-L3, L3-L4, L4-L5, L5-S1 facet block under fluoroscopic guidance five levels.
SURGEON: Harry Richard, M.D.
ASSISTANT: Pamela Walker, C.R.N.A.
ANESTHESIOLOGIST: Caroline Moss, M.D.
ANESTHESIA: Local plus IV conscious sedation.
COMPLICATIONS: None. 
BLEEDING: None. 

INDICATIONS FOR PROCEDURE:  Severe intractable pain that was not responding to conservative medical therapy, physical therapy or previous epidural steroid injections.  

DESCRIPTION OF THE PROCEDURE:  The procedure, risks, and benefits were explained to the patient, all questions were answered and consent was obtained.  Patient     was taken to the Operating Room and place in a decubitus-prone position on the operating table.  Monitors were applied and sedation started by the anesthesiologist. 

Then the lumbosacral area was prepped and draped in under surgical sterile conditions. Using fluoroscopic guidance AP and oblique views the right L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1 facets were located.  The skin and subcutaneous tissues were infiltrated with 1.0% lidocaine, 1 ml per each level.  Then a 22-gauge, 3-inch spinal needle was directed toward the facet joint at each level using fluoroscopic guidance, oblique view under tunnel vision technique. Correct needle tip placement was confirmed using AP and lateral views and aspiration was negative for CSF and blood at each level.  No paresthesias were noted during the needle placement.  Then 1 ml of 0.25% Marcaine and 10 mg of Kenalog were injected per level. The patient tolerated the procedure well.

Then the left L1-L2, L2-L3, L4-L5, L5-S1 were located under oblique view of fluoroscopic guidance.  The skin and subcutaneous tissues were infiltrated with lidocaine 1.0%; 2 ml per level and then a 22-gauge, 3-inch spinal needle was directed toward the facet joint at each level using fluoroscopic guidance, oblique view under tunnel vision technique. Correct needle tip placement was confirmed using AP and lateral views and aspiration was negative for CSF and blood at each level.  No paresthesias were noted during the needle placement.  Then 1 ml of 0.25% Marcaine and 10 mg of Kenalog were injected per level. The patient tolerated the procedure well. No complications were noted.  The patient was transferred to the Recovery Room in stable condition.