Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Pain Management
Sample Name: Lumbar Facet Injections

Description: Lumbar facet injections done under fluoroscopic control. Lumbar spondylosis.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Lumbar spondylosis.

POSTOPERATIVE DIAGNOSIS: Lumbar spondylosis.

OPERATION PERFORMED: Lumbar facet injections done under fluoroscopic control.

ANESTHESIA: Local and IV.

COMPLICATIONS: None.

DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place. The skin was prepped and draped in a sterile classical fashion. The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter. The patient was given oxygen, intravenous sedation and analgesics as needed. The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's "Scottie dog" and the opening of the facet.

After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets. A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique. After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule. After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet. The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.

Keywords: pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples