Sample Opnote – Thoracic/Lumbar Medial Branch Radiofrequency Ablation




Procedure: Lumbosacral Radiofrequency Ablation

Levels Treated: L3-L4,L4-L5,L5-S1

Laterality: Left

Pre-op diagnosis:

M47.817 – Spondylosis without myelopathy or radiculopathy, lumbosacral 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 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 80% improvement in the patient’s usual pain for the expected duration of time. 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 positioned prone on the fluoroscopy table. All pressure points were padded and checked routinely. The patient’s level of consciousness was monitored throughout. The back was widely sterilized using a Betadine solution and was draped in a sterile manner.

Lidocaine was used to make a skin wheal approximately 2 cm lateral and 3 cm inferior to the junction of the superior articulating process and the transverse process of L3 on the left. The subcutaneous tissue was then anesthetized and a RF needle with a 15 mm curved active tip was advanced in an oblique fashion (using fluoroscopic guidance in the AP and oblique views) until the needle tip was positioned at the transitional junction between the superior articulating process and the transverse process. 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 1 milliamps. Stimulation up to 3 milliamps did not reveal any neuromuscular response in the ipsilateral lower extremity. Thereafter, 0.5 mL of 1% preservative-free lidocaine without epinephrine was slowly injected with ease and without incidence. Non-pulsed radiofrequency ablation was then performed at a temperature of 80 degrees Celsius at the probe tip for a duration of sixty seconds. The medial branch nerve was also ablated at L4, L5, and the dorsal ramus at the sacral ala with the same results and without complications, on the left. 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}}