River North Same Day Surgery Center
One East Erie, suite # 300
Chicago, Illinois 60611
Operative Report
Patient Name
:
GIBSON, MARGARET
Date of Birth
:
04/03/62
MR#
:
334-66-2383
Date of service : 01/02/08
Surgeon: Axel Vargas, M.D.
Preoperative diagnosis:
1. Lumbo-sacral spondylosis
2. Central and para-central disk bulge at L5-S1 level, resulting in a right sided L5S1 radiculopathy
3. Right-sided sacro-illiac joint dysfunction.
Postoperative diagnosis:
1. Lumbo-sacral spondylosis
2. Central and para-central disk bulge at L5-S1 level, resulting in a right sided L5S1 radiculopathy
3. Right-sided sacro-illiac joint dysfunction.
Operation: Right side fluoroscopy guided diagnostic/therapeutic SI joint injection
Injectate: Dexamethasone 10 mgs, Wydase 75 UI, Isovue 300, Lidocaine 2%.
Anesthesia: Local
EBL: None
Complications: None
Procedure: The patient was identified, examined and consented for the above
mentioned procedure. She then was taken to the fluoroscopy suite and placed prone on
the fluoroscopy table; the skin was then prepped compulsively with Duraprep and
draped in the usual fashion. Anatomical landmarks were properly identified via palpation
and direct fluoroscopy imaging, and the skin was then topographically marked with a
surgical marker. At this point the skin and subcutaneous tissues were generously
anesthetized with 2% Lidocaine w/o epinephrine.
Via strict aseptic technique and under direct fluoroscopy guidance a 22G Quincke spinal
needle was advanced into the right SI joint distally. The patient experienced no
paresthesia, and there was no heme retrieved. At this point 1.5 cc of contrast material
(Isovue 300) were delivered into the SI joint in order to confirm proper needle placement;
PAGE 2, GIBSON, MARGARET
a well delineated right SI joint was visualized on fluoroscopy. At this point, 10 mgs of
Dexamethasone, Bupivacaine 05% without epinephrine and Wydase 75 UI were
delivered into right SI joint without any resistance and under direct fluoroscopic
visualization. The needle was then withdrawn and the skin was then cleaned with
alcohol and dressed by the OR nurse. The patient tolerated the procedure well, and
experienced no vital signs changes throughout. She was then transferred ambulatory to
the recovery room where she was observed by the recovery room nurse for a period of
15-20 minutes prior to being discharged; the patient was discharged home in stable
conditions.
We will follow up with this patient via telephone call within the next 24-36 hours and I will
like to see her again in 6-8 weeks for a follow up visit. I also issued a prescription for SIJ
dysfunction focused physical therapy, and encouraged Mrs. Gibson to pursue it.
Finally I encouraged her again to follow upon with Dr. Adam Bennett at his convenience.
________________
Axel Vargas, M.D.,
CC: Adam Bennett M.D.,
Northwestern Orthopaedic Institute
680 North Lake Shore Drive, suite # 1028
Chicago, Illinois 60611
Chart