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PREOPERATIVE DIAGNOSES

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PREOPERATIVE DIAGNOSES Powered By Docstoc
					PREOPERATIVE DIAGNOSES:
1.   Lumbar disk protrusion at L2-L3, L3-L4, L4-L5 level.
2.   Left-sided S1 lumbar radiculopathy.
3.   Left supraspinatus tendinitis.
4.   Hypertension.
5.   Non-insulin-dependent diabetes mellitus.
6.   Chronic myofascial pain syndrome.

POSTOPERATIVE DIAGNOSES:
1.   Lumbar disk protrusion at L2-L3, L3-L4, L4-L5 level.
2.   Left-sided S1 lumbar radiculopathy.
3.   Left supraspinatus tendinitis.
4.   Hypertension.
5.   Non-insulin-dependent diabetes mellitus.
6.   Chronic myofascial pain syndrome.

PROCEDURE PERFORMED:
1.   L4-L5 translaminar lumbar epidural steroid injection.
2.   Left-sided S1 transforaminal epidural steroid injection.
3.   Lumbar epidurography x2.
4.   Fluoroscopy for needle localization x2.
5;   Lumbar spine x-ray films x4.
6.   Lumbar spine regional anesthesia with 1% lidocaine.
7.   IV conscious sedation with fentanyl and Versed (high dose).
8.   Pulse oximetry.

SURGEON:                   Tulsidas R. Gwalani, M.D.
ANESTHESIA:                Lumbar spine regional anesthesia with 1% lidocaine.
                           IV conscious sedation with fentanyl and Versed.

COMPLICATIONS:
Nil.

ESTIMATED BLOOD LOSS:
Minimal.

HISTORY OF PRESENT ILLNESS:
The patient has a severe escalation of low back pain shooting down the left leg
with tingling, numbness, and paresthesia. Cold weather and rainy season made her
pain worse. She codes her pain at 9/10 on VA scale. She has a tingling,
numbness, and paresthesia in the left leg and left foot. She had a previous
epidural steroid injection done with significant pain relief for three to four
months.


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OBJECTIVE FINDINGS:
She is alert and oriented x3, afebrile, obese, diabetic.
There is increased lumbar lordosis. Range of motion of the lumbar spine is
restricted. Paravertebral muscle spasm and localized tenderness is present. In
the left spine area in the left gluteal region right-sided sitting SLR is 70-80
degrees, left-sided sitting SLR is 60-70 degrees. There is diminished sensation
to light touch along the lateral border of the left foot.

DESCRIPTION OF PROCEDURE:
The patient has been informed about the risks and benefits of the procedure.
Risks like injury to nerve root, paralysis, paraplegia, quadriplegia, increased
pain, no relief of pain, infection, epidural abscess, hematoma, hemorrhage,
allergic reaction, immunologic reaction, bladder or bowel dysfunction, and even
death have been explained to the patient. The patient understood and agreed to
the procedure. Informed consent was obtained. After informed consent was
obtained, an IV was started. The patient was placed in prone position on the
fluoroscopy table. Cardiac monitoring was placed on the fluoroscopy table.
Vital signs and cardiac parameters stayed within the normal range, as per nursing
records. Intravenous conscious sedation fentanyl and Versed was given, as per
nursing records. The back was prepped and draped with povidone and iodine and
isolated with sterile technique. The lumbosacral spine area was isolated in
sterile fashion. The fluoroscope was covered with a Snap Cap.

L4-5 Translaminar Lumbar Epidural Steroid Injection:
The fluoroscope was rotated to the AP projection. After local infiltration with
1% Xylocaine, a 20-gauge 3-1/2-inch Tuohy needle was placed such that it entered
the epidural space at L4-5 level with the loss of resistance technique. After
negative aspiration for blood and cerebrospinal fluid, 2 mL of radiopaque
Omnipaque dye was injected. The dye was found to travel up to the middle of L3
vertebral body and down to the level of S2 neural foramen. After negative
aspiration for blood and CSF, 1 mL of 80 mg Depo-Medrol, 1 mL of 4% lidocaine
with 1 mL of preservative-free normal saline and 1 mL of radiopaque Omnipaque dye
mixture was injected into the epidural space. Before injection, epidurogram with
hard x-ray films were taken.

After steroid injection, needle was removed.

Left-Sided S1 Transforaminal Epidural Steroid Injection: The fluoroscope was
rotated to the AP projection. After local infiltration with 1% Xylocaine, a #22-
gauge 3-1/2-inch spinal needle was placed such that it entered the left S1 neural
foramen with ease. After negative aspiration for heme and cerebrospinal fluid, 2
cc of radiopaque Omnipaque dye was injected. The dye was found to travel along
the left S1 dural nerve root sleeve and into the left medial epidural space. In
the lateral projection, the needle was found to lie within the body of the
sacrum. The dye was found to travel longitudinally along the epidural space.
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After a negative aspiration for heme and cerebrospinal fluid, a 2 cc mixture of
0.5 cc of 4% lidocaine plus 0.5 cc of 40 mg Depo-Medrol with 0.5 cc normal saline
and 0.5 cc of radiopaque Omnipaque dye was injected. The needle was taken out.

Lumbar epidurography was performed. Lumbar spine x-ray films x4 were taken for
documentation and confirmation. Fluoroscopy was used for the needle localization
x2. Lumbar spine regional anesthesia with 1% lidocaine was given. IV conscious
sedation was given with fentanyl and Versed (high dose).

The patient tolerated the procedure well. There were no complications or
sequelae during the procedure. The patient was stable postprocedure. The
patient has been transferred to the PACU.

The patient has been recommended to make a followup appointment in one week.




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