Sample Opnote – Diagnostic Cervical Medial Branch Block

[This is a sample procedure note and may not match the corresponding guide exactly: As with all procedures there will be slight variations based on body habitus, technique preference, laterality, etc. Treat this as a starting point for a template. The brackets {{ }} are used in the body as placeholders for dynamic variables.]

[Written as if right sided at C3-C4, C4-C5, C5-C6. Full procedure technique and overview here.]




Procedure: Diagnostic Cervical Medial Branch Block

Levels Treated: C3-C4,C4-C5,C5-C6

Laterality: Right

Pre-op diagnosis:

M47.812 – Spondylosis without myelopathy or radiculopathy, cervical region

Post-op diagnosis: Same

Anesthesia: MAC

Pre-Procedure Review: The initial consultation report has been reviewed and there are no changes with regard to the patient’s medical, social history and review of systems. The patient states that the symptoms are stable and unchanged since the last visit. My findings on physical examination today are grossly consistent with those documented on the previous follow-up note, at which time today’s procedure was scheduled. I will proceed today with the scheduled procedure and see the patient back for follow-up. The patient states understanding of the plan, and is in agreement.

Indication: To determine the extent to which degenerative arthritis of the cervical facet joints is causing the pain reported by the patient. If this block reproducibly results in at least 80% relief of the patient’s usual pain for an appropriate duration of time (based on the local anesthetic used), then it can be concluded that degenerative arthritis of the cervical facet joints is the primary source of the patient’s pain. Positive diagnostic blocks are an indication for subsequent therapeutic treatment.

Description: The history and physical examination were reviewed to ensure accuracy, and the details of the procedure were reviewed with the patient who understands all of the risks and benefits involved. All questions have been answered, and the patient is aware of all alternative therapeutic options. An informed consent was obtained, and the patient was directed to the procedure room. A “time-out” with two active identifiers of the patient, the procedure, and the site was performed. The patient was positioned in the {{left}} lateral decubitus position on the fluoroscopy table. All pressure points were padded and checked routinely. The patient’s blood pressure, heart rate, pulse oximetry, and level of consciousness were monitored throughout. The neck was widely sterilized using a Betadine solution and was draped in a sterile manner.

A “non-sting” local anesthetic solution was used to make a skin wheal directly over the articular waist of the C3 vertebral body on the right. The subcutaneous tissue was then anesthetized, and a Quincke needle was advanced in an target fashion (using fluoroscopic guidance in the AP view) until the needle tip was positioned at the articular pillar. Proper needle position was confirmed in multiple fluoroscopic views. An aspiration test was negative for blood, CSF, or other fluid. Thereafter, 0.5 mL of 1% Lidocaine (preservative-free) without epinephrine was slowly injected with ease and without incident. This procedure was then repeated in the same fashion and with the same results at C4, C5, and C6, on the {{right}}. Total fluoroscopy time was {{ }}minutes ({{ }}mGy).

The procedure was performed uneventfully and was well-tolerated by the patient. The patient was transferred to an observation room and recovered without incident. No adverse events were noted, and the patient was discharged home in stable condition. All potential side effects and adverse events have been discussed with the patient. The patient has been instructed to call my clinic at the first sign of an adverse event, or with any other concerning symptoms. A follow-up appointment has been made.

Anesthesia Addendum: {{standard anesthesia addendum if applicable}}