[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 left sided, assuming a block at L2 and L3. Full procedure technique and overview here.]
Surgeon:
Patient:
DOS:
Procedure: Lumbar Sympathetic Nerve Block
Levels Treated: L2, L3
Laterality: Left
Pre-op diagnosis:
G90.522 – Complex regional pain syndrome I of left lower limb
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 block sympathetic outflow to a lower limb or other specified site in order to attenuate sympathetically-mediated pain. If done as a series of regularly spaced blocks over a short duration of time, this procedure can “re-program” the nervous system to achieve a more balanced state between the sympathetic and parasympathetic systems.
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 the risk 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 prone 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 mid back was widely sterilized using a Betadine solution and was draped in a sterile manner.
The L2 vertebral body was visualized under fluoroscopy in the {{left}} oblique view, and a Quincke needle with a 15 degree bend at the tip was advanced in a “target approach” until it made contact with the antero-lateral edge of the midpoint of the vertebral body. The needle was then directed antero-medially until the tip was positioned halfway between the middle of the vertebral body and its lateral edge, along its anterior aspect. Proper needle position was confirmed in both the AP and lateral views. Thereafter, 5 mL of radiopaque contrast solution was slowly injected under live fluoroscopy without incident, which showed a linear cephalo-caudal spread of dye along the sympathetic chain. At that point, 7mL of 0.25% preservative free bupivacaine (without epinephrine) was slowly injected with frequent aspiration tests that were all negative for blood and CSF. The procedure was repeated in the same fashion and with the same results at the L3 vertebral body, also on the {{left}} side. The entire volume of medication was injected without incident and the procedure was well tolerated by the patient. Total fluoroscopy time was {{ }}minutes ({{ }}mGy).
The patient was transferred to an observation room and recovered without incident. Signs and symptoms of a successful block (e.g. warmth/flushing/vasodilation of the lower extremity) were noted in the recovery room. No adverse events were noted, and the patient was discharged home in stable condition, without any signs of neuromuscular weakness. 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}}