Download North Texas Affiliated Medical Group

OPERATIVE REPORT
PATIENT:
DATE: 5/6/2017
MR#
PROCEDURE:
1. Left T6 Medial Branch Block
2. Left T7 Medial Branch Block
REFERRING PHYSICIAN:
PATIENT’S PCP:
PHYSICIAN: Michael P. Zeringue, M. D.
PREOPERATIVE DIAGNOSIS: Thoracic Spondylosis (721.2)
POSTOPERATIVE DIAGNOSIS: Same
PRIOR INJECTION TREATMENT:
ANESTHESIA: IV Sedation Provided by Anesthesia Services
COMPLICATIONS:
CONSENT: Informed consent was given and signed informed consent document was obtained. A full description
of the procedure was provided including benefits as well as possible complications, including but not limited to
pain, infection, bleeding, injury to spinal nerve or spinal cord, meningitis, neuritis, allergic reaction to medications,
need for further procedures or surgery.
OPERATIVE PROCEDURE: The patient was brought to the procedure room and placed on the exam table in a
comfortable prone position. The sterile field was prepped by Duraprep and sterile drapes. Local anesthesia was
provided by local infiltration of 2ml of 1% lidocaine buffered with sodium bicarbonate over each injection site.
A 25-gauge 3.5 inch spinal needle was placed overlying the left T1 medial branch and using fluoroscopic guidance,
the needle was advanced down to the level of bone. Next, a 25-gauge 3.5 inch spinal needle was placed overlying
the left T1 medial branch and using fluoroscopic guidance, the needle was advanced down to the level of bone.
Attempted aspiration yielded no blood at any level. Subsequently, 0.2 ml of Omnipaque-240 contrast material was
injected under direct visualization at each level, which demonstrated local uptake and no vascular spread.
The following medications were mixed: 2ml of 0.75% Marcaine
1ml of 1% lidocaine
0.5ml of this mixture was injected at each level. The needles were then removed.
The patient tolerated the procedure well, there were no complications. After standard anesthesia recovery, he was
ready for discharge. He was provided with contact information and instructed to call regarding any concerning
symptoms or questions.
IMPRESSION:
1. Successful 2 level thoracic medial branch block done with Marcaine and lidocaine.
2. The patient is to follow up in 1 week to assess the efficacy of this treatment.
The patient was given an 24 hr pain diary.
_____________________________
Michael P. Zeringue, M. D.
Pontchartrain Bone & Joint
582712024