Lakeshore Surgery Center
7200 North Western Avenue
Chicago, Illinois 60645
Operative Report
Patient Name
:
HARO, BENJANIM
Date of Birth
:
02/14/58
MR#
:
331-62-3225
Date of service :
11/22/08
Surgeon
Axel Vargas, M.D.,
:
Preoperative diagnosis:
1. Chronic lower back pain syndrome
2. Multilevel disk disease and facet arthropathy of the lumbosacral spine.
3. Discogenic lower back pain secondary to lumbar spondylosis at L4-L5 and
L5-S1 levels.
4. Right-sided L5 radiculopathy.
Postoperative diagnosis:
1. Chronic lower back pain syndrome
2. Multilevel disk disease and facet arthropathy of the lumbosacral spine.
3. Discogenic lower back pain secondary to lumbar spondylosis at L4-L5 and
L5-S1 levels.
4. Right-sided L5 radiculopathy.
Operation: Fluoroscopy guided L3-L4, L4-L5 and L5-S1 provocative lumbar
discography with post-discography CT.
Injectate: Non-ionic myelographic contrast material (Isovue 300mgs I/ml) Cefazolin 1gr,
Ropivacaine (Noropin) 025% without Epinephrine, Lidocaine 2%.
Anesthesia: MAC without narcotic analgesia
EBL: None
Complications: None
Procedure: The patient was identified, examined and consented for the above
mentioned procedure. A peripheral IV access was readily obtained in the holding room
and an intravenous infusion of Cefazolin 1gr IV was initiated 45 minutes prior to the
actual procedure. He was then transferred to the fluoroscopy suite and positioned prone
on the fluoroscopy table. Monitors were applied and based down and monitored
anesthesia care (MAC) was uneventfully started by the anesthesia team. At this point,
the skin was prepped compulsively with Duraprep and draped in the usual fashion.
Page 2, Re: HARO, BENJAMIN
Anatomical landmarks were properly identified via palpation and direct fluoroscopy
imaging, and topographically marked with a sterile surgical marker. At this point the skin
and subcutaneous tissues were generously anesthetized with 2% Lidocaine without
Epinephrine.
Via strict, aseptic, sterile technique and under direct fluoroscopy guidance three 6-inches
22G Quincke spinal needles were sequentially advanced from the contralateral (left)
side approach with attention to remain in a trajectory ventrolateral to each corresponding
superior articular process (SAP) and midway between the corresponding vertebral
endplates. Each corresponding needle was uneventfully advanced into the middle 1/3 of
each corresponding disk. Compulsive proper needle placement confirmation was
obtained at this point via fluoroscopy on three different views, i.e., AP/oblique, and
lateral views. The patient experienced no paresthesia, there was no heme and no CSF
was retrieved. At this point a careful assessment of the patient mental status was
obtained to assure full awareness and therefore diminish potential false positives.
With the patient fully awake, alert and oriented, 3ml of a solution containing Cefazolin
and Isovue 300 was sequentially injected with a manometric syringe starting at the
control level (L3-L4) and sequentially proceeding distally to the L4-L5 and L5-S1 disks.
Prior to proceed with the next disk, each previous tested disk level was injected with a
solution of Lidocaine 2%, Ropivacaine 025% and Kenalog 40mgs, to further avoid false
positives with the following disks levels.
Opening pressures were carefully recorded at each level, as well as the pressure at
which the patient reported a concordant (or discordant) pain. The morphology of each
disk was noted as well.
These are the results:
►L3-L4
Level Injected
►1ml
Contrast/Abx injected
Opening Pressure
(PSI)
End Point
►Firm
2.5ml
3ml
Soft
0 ►1 2 3 4 5 6 7 8 9 10
►None Mild
Pain Classification
Contrast Pattern (Disk
Morphology)
Relief with Local
Anesthetic/Steroid
2ml
15psi
Pain Scale (NPS)
Pain Severity
1.5ml
Moderate
Concordant
►Cotton Ball
Lobular/Horseshoe
Severe
Excruciating
►Discordant
Degenerated
Fissured
None Some Complete ►Indeterminate
Ruptured
Page 3, Re: HARO, BENJAMIN
►L4-L5
Level Injected
Contrast/Abx injected
1ml
Opening Pressure
(PSI)
End Point
►Firm
2.5ml
3ml
Soft
0 1 2 3 4 5 6 7 8 9 ►10
Pain Severity
Mild
►Severe
Moderate
►Concordant
Pain Classification
Cotton Ball
Lobular/Horseshoe
Excruciating
Discordant
Degenerated
Fissured ► Ruptured
►None Some Complete Indeterminate
Level Injected
L5-S1
Contrast/Abx injected
1ml
Opening Pressure
(PSI)
End Point
►1.5ml
2ml
2.5ml
3ml
15psi
►Firm
Soft
0 1 2 3 4 5 6 7 8 ►9 10
Pain Scale (NPS)
Pain Severity
Mild
Moderate
►Severe
►Concordant
Pain Classification
Contrast Pattern (Disk
Morphology)
Relief with Local
Anesthetic/Steroid
2ml
15psi
Pain Scale (NPS)
Contrast Pattern (Disk
Morphology)
Relief with Local
Anesthetic/Steroid
►1.5ml
Cotton Ball
Lobular/Horseshoe
Excruciating
Discordant
Degenerated ► Fissured
Ruptured
None ►Some Complete Indeterminate
The needles were then withdrawn and the skin was then cleaned with Duraprep removal
lotion and dressed by the OR nurse.
The patient tolerated the procedure well, and experienced no vital signs changes
throughout. He was then transferred to the CT suite to undergo a post-discography CT.
Upon completion he was then transported to the recovery room ambulatory where he
was observed by the recovery room nurses for a period of 2hrs prior to being
discharged. Here he received an dose of intravenous Toradol 30mgs and oral Norco
10/325 mgs.
The patient was then discharged home in stable conditions. We will follow up with this
patient via telephone call within the next 24-36.
Page 4, Re: HARO, BENJAMIN
Similarly, I gave specific verbal and written instruction to refrain from driving at least for
12 hours after discharge. I also instructed him to apply ice packs to the needle entry
points for the first 24 hours and thereafter warmth compresses for the following 24
hours. I issued a prescription for Norco 10/325mgs 1-2 TAB PO QID PRN only.
Finally, I instructed the patient to follow up promptly with Dr. Mark Gerber and
Dr. Donald Kucharzyk at their convenience to determine ne further disposition.
Axel Vargas, M.D.,
CC: Mark Gerber M.D.,
3518 West Fullerton Avenue
Chicago, Illinois 60647
Donald W. Kucharzyk, M.D.
Orthopaedic Pediatric & Spine Institute
11360 Broadway
Crown Point, Indiana 46307
Connie Simms (W/C Adjuster)
Claim Number 2700336092-001
(847) 240-8149
Chart