River North Same Day Surgery center
One East Erie, Suite 300
Chicago, Illinois 60611
Operative Report
Patient Name
:
McCANN, MARIE
Date of Birth
:
03-27-49
MR#
:
350-40-0233
Date of service :
05/28/08
Surgeon: Axel Vargas, M.D.,
Preoperative diagnosis:
1. Multilevel cervical spondylosis.
2. Multilevel disk disease of the cervical spine at the C5-C6 and C6-C7levels.
3. Multilevel Neuroforaminal stenosis.
4. Left-sided cervical radiculopathy
Postoperative diagnosis:
1. Multilevel cervical spondylosis.
2. Multilevel disk disease of the cervical spine at the C5-C6 and C6-C7levels.
3. Multilevel Neuroforaminal stenosis.
4. Left-sided cervical radiculopathy
Operation: Interlaminar, fluoroscopy guided cervical epidural steroid injection.
Injectate: Kenalog 80 mgs, Ropivacaine 0.25%, Vitrase 200 UI, Isovue 300,
Lidocaine 2%.
Anesthesia: Local
EBL: None
Complications: None
Procedure: Mrs. McCann 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; Monitors were then applied and based lined.
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 1%
Lidocaine without epinephrine.
Page 2, Re: MCCANN, MARIE
Via strict, aseptic, sterile loss of resistance (LOR) to normal saline solution-technique
and under direct fluoroscopy guidance a 20G Touhy needle was advanced into the
epidural space at the C5-C6 level. The patient experienced no paresthesia, there was no
heme and no CSF was retrieved. At this point 3cc of contrast material (Isovue 300) were
delivered into the epidural space in order to confirm proper needle placement; a well
delineated epidurogram was visualized on fluoroscopy on three different views, i.e.,
AP/Oblique and lateral views. No radiological evidence of intravascular contrast spread
or intrathecal migration was appreciated.
At this point, 80 mgs of Kenalog (non particulate steroid), Ropivacaine 0.25% and
Vitrase 200 UI were delivered into the epidural space without any resistance, followed by
a flush of 3cc of preservative free NSS (PFNSS). The patient exhibited neither motor nor
sensory nerve block after 60 seconds.
The needle was then withdrawn and the skin was then cleaned with alcohol and dressed
by the OR nurse. Mrs. McCann tolerated the procedure well, and experienced no vital
signs changes throughout. She was then transferred to the recovery room ambulatory,
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 Mrs. McCann via telephone call within the next 24-36 hours and I
will like to see her again in 2-3 weeks for a follow up visit and a second interlaminar
cervical ESI if indicated. Finally I encouraged the patient to follow up with Dr. Srdjan
Mirkovic at his convenience so that he can assess Mrs. McCann’ response to this
modality of treatment.
__________________
Axel Vargas, M.D.,
CC: Srdjan Mirkovic, M.D.,
Northwestern Orthopaedic Institute
680 North Lake Shore Drive, suite # 1028
Chicago, Illinois 60611
CC: Dawn Subatich, R.N.,
Northwestern Orthopaedic Institute
680 North Lake Shore Drive, suite # 1028
Chicago, Illinois 60611
Chart