Sample Opnote – Cervical Medial Branch Radiofrequency Ablation

[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: Cervical Radiofrequency Ablation

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: Local

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 ablate the nerves involved in the transmission of pain from arthritic facet joints. The patient has undergone two separate diagnostic medial branch blocks/facet blocks, both of which produced at least 75-80% improvement in the patient’s usual condition for the expected duration of time (with pain relief accompanied by an increase in functional capacity). Based on the results of these two blocks, the patient is an ideal candidate for radiofrequency ablation of the same medial branch nerves, which should provide significant long-term relief of the facet mediated pain.

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 placed in the prone position on the fluoroscopy table. All pressure points were padded and checked routinely. The patient’s vital signs were checked every 5 minutes and the level of consciousness was continually assessed. 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 overlying the midpoint of the C3 articular pillar, on the right, and the subcutaneous tissue was subsequently anesthetized. A 10 cm curved-tip radiofrequency needle was advanced in a posterior-to-anterior fashion (using fluoroscopic guidance in the AP view) until the needle tip was positioned along the lateral waist of the articular pillar. Proper needle position was confirmed in multiple fluoroscopic views. An aspiration test was negative for blood, CSF, and other bodily fluids. The guide needle was removed. A radiofrequency probe was then inserted through the cannula, and motor stimulation revealed paraspinous muscle contraction at less than 0.5 milliamps. Stimulation up to 3 milliamps did not reveal any neuromuscular response in the ipsilateral upper extremity. Sensory stimulation (at less than or equal to 1.0 milliamps), on the other hand, produced pressure/pain in the same distribution as the patient’s usual pain. Thereafter, 0.5 mL of 2% preservative-free lidocaine without epinephrine was slowly injected with ease and without incident. Non-pulsed radiofrequency ablation was then performed at a temperature of 80 degrees Celsius at the probe tip for a duration of sixty seconds. This procedure was the 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 grounding pad was carefully removed. The site was checked and found to be free of any irritation.

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}}