Lakeshore Surgery Center
7200 North Western Avenue
Chicago, Illinois 60645
Operative Report
Patient Name
:
BERREZUETA, RODRIGO
Date of Birth
:
11/03/79
MR#
:
5455 (Lakeshore Surgery)
Date of service :
01/10/09
Surgeon: Axel Vargas, M.D.
Preoperative diagnosis:
1. Lumbo-sacral spondylosis.
2. L5-S1 lumbar radiculopathy
Postoperative diagnosis:
1. Lumbo-sacral spondylosis.
2. L5-S1 lumbar radiculopathy
Operation: Interlaminar fluoroscopy guided L5-S1 Lumbar epidural steroid injection
(ESI).
Injectate: Kenalog 80 mgs, Bupivacaine 0.25%, Isovue 200, Vitrase 200 UI,
Lidocaine 2%.
Anesthesia: MAC
EBL: None
Complications: None
Procedure: Mr. Berrezueta was identified, examined and consented for the above
mentioned procedure. He was then taken to the fluoroscopy suite and positioned on the
fluoroscopy table in a prone position; Monitors were 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 topographically marked with a surgical marker. At this point the skin and
subcutaneous tissues were generously anesthetized with 2% Lidocaine without
epinephrine.
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 L5-S1 level. The patient experienced no paresthesia, there was no
heme and no CSF was retrieved.
PAGE 2, BERREZUETA, RODRIGO
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), Bupivacaine 025% without
epinephrine 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The needle was then withdrawn and the skin was then cleaned with alcohol and dressed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. Mr. Berrezueta tolerated the procedure well, and experienced no vital
signs changes throughout. He was then transferred to the recovery room ambulatory,
where 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 closely with this patient via telephone call within the next 12-24 hours
and I will like to see him again in 8-10 weeks.
Finally, I again encouraged him again to engage in focused physical therapy to strengthen
his abdominal and paraspinous musculature and therefore further increase his clinical
improvement and restore his ability to return to unrestricted work.
__________________
Axel Vargas, M.D.,
CC: Ravi .Barnabas, M.D.,
Dr. Ruben Bermudez
Herron Medical Center
1150 North State Street
Chicago, Illinois 60610
Atty. James Gumbinar
180 North Michigan Avenue
Chicago, Il. 60601
Chart