DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Complex regional pain syndrome of the right upper extremity.
2. Lumbar discogenic disease.
3. Right radiculopathy.
POSTOPERATIVE DIAGNOSES:
1. Complex regional pain syndrome of the right upper extremity.
2. Lumbar discogenic disease.
3. Right radiculopathy.
OPERATION PERFORMED:
1. Lumbar epidural steroid injection.
2. Right stellate ganglion block.
SURGEON: John Doe, MD
ANESTHESIA: Local with IV sedation of 30 mg ketamine, 4 mg Versed and 100 mcg fentanyl.
ESTIMATED BLOOD LOSS: Zero.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the operating suite for lumbar epidural steroid injection and right stellate ganglion block. The patient was placed in the prone position with a pillow under her abdomen.
The lumbar area was prepped with Betadine x3 and sterilely draped. Utilizing the fluoroscope, the L5-S1 interspace was identified and lidocaine 1% was infiltrated subcutaneously. A 20-gauge Tuohy epidural needle was advanced into the epidural space with loss of resistance to air. There was no blood or CSF aspirated. Omnipaque was given. See epidurogram below.
Then, 5 mL of Marcaine 0.25% with 9 mg Celestone was injected and the needle withdrawn. The patient tolerated the procedure well. Next, the patient was placed in the supine position with the pillow underneath her right shoulder. The right anterior neck was prepped with chlorhexidine and draped with sterile towels.
Under fluoro and right oblique view, the anterolateral aspect of the C7 vertebra was identified and marked on the skin. Lidocaine 1% was injected subcutaneously over this area.
A 25-gauge spinal needle was then advanced under direct fluoroscopy until it contacted the C7 vertebra on the anterolateral aspect. There was negative aspiration for blood or CSF.
Omnipaque 1 mL 180 was given, which spread in a superior and inferior direction along the anterolateral aspect of the cervical vertebra, which confirmed that the needle tip was within the correct tissue plane.
Lidocaine 2 mL, 1%, was injected as a test dose. There was no adverse reaction. Therefore, a total of 6 mL of Marcaine 0.25% with 2 mL of preservative-free normal saline was injected and the needle withdrawn.
The patient tolerated the lumbar epidural steroid injection and right stellate ganglion block well.
EPIDUROGRAM INTERPRETATION: After 2 mL of Omnipaque 180 was injected through the epidural needle, the AP view showed that the epidural spread was primarily in the right epidural space with epidural fat noted, and on lateral view, the dye was in the posterior epidural space, confirming that the needle tip was within the epidural space.