Lakeshore Surgery Center
7200 North Western Avenue
Chicago, Illinois 60645
Operative Report
Patient Name
:
GUZMAN, GREGORIO
Date of Birth
:
05/09/51
MR#
:
331-48-0544
Date of service : 09/30/08
Surgeon: Axel Vargas, M.D.,
Preoperative diagnosis:
1. C3-C4 and C6-C7 cervical disk herniations
2. Cervical radiculopathy.
3. Degenerative disk disease and facet arthropathy at the L4-L5 and L5-S1 levels
with resulting bilateral neuroforaminal stenosis at these levels.
4. S/P left rotator cuff repair.
Postoperative diagnosis:
1. C3-C4 and C6-C7 cervical disk herniations
2. Cervical radiculopathy.
3. Degenerative disk disease and facet arthropathy at the L4-L5 and L5-S1 levels
with resulting bilateral neuroforaminal stenosis at these levels.
4. S/P left rotator cuff repair.
Operation: Interlaminar, fluoroscopy guided C3-C4 and C6-C7 cervical epidural steroid
injections.
Injectate: Kenalog 40 mgs, Ropivacaine 0.25%, Vitrase 200 UI, Isovue 300,
Lidocaine 2%.
Anesthesia: Local
EBL: None
Complications: None
Procedure: Mr. Guzman was identified, examined and consented for the above
mentioned procedure. He 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.
Page 2, Re: GUZMAN, GREGORIO
At this point the skin and subcutaneous tissues were generously anesthetized with 1%
Lidocaine without epinephrine.
Via strict, aseptic, sterile loss of resistance (LOR) to normal saline solution-technique
and under direct fluoroscopy guidance two 20G Touhy needle were advanced into the
epidural space firstly at the C3-C4 and then C6-C7 levels. 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 at the two levels depicted.. No
radiological evidence of intravascular contrast spread or intrathecal migration was
appreciated.
At this point, 40 mgs of Kenalog (non particulate steroid), Ropivacaine 0.25% and
Vitrase 200 UI were delivered into each Touhy needle and into the corresponding
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. Guzman tolerated the procedure well, and experienced no vital
signs changes throughout. He was then transferred to the recovery room ambulatory,
where he 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 Mr. Guzman via telephone call within the next 24-36 hours and I
will like to see him again in 2-3 weeks for a follow up visit and a second set of
interlaminar cervical ESI ‘s if indicated. Finally I encouraged the patient to engage in
focused physical therapy to strengthen his paraspinous musculature and therefore
further increase his clinical improvement.
__________________
Axel Vargas, M.D.,
CC: Ravi .Barnabas, M.D.,
Dr. Ruben Bermudez
Herron Medical Center
1150 North State Street
Chicago, Illinois 60610
Chart