Date

PHYSICIAN: Dr. Abou Hussain, Pain Clinic ASSISTANT

ANESTHESTIST PREOPERATIVE DIAGNOSIS

1. Post laminectomy syndrome.

2. Lumbar radiculitis

POSTOPERATIVE DIAGNOSIS

1. Post laminectomy syndrome.

2. Lumbar radiculitis

PROCEDURE

1. Use of fluoroscopy for needle placement

2. Epidural myelography without thecal sac puncture

3. Injection of local anesthetic and steroid into the right L5-S1 interlaminar epidural space

INDICVATIONS

** is a 32-year-old male with post laminectomy syndrome and back and leg pain. He has had previous
laminectomy at L4-5. He comes in today with a very severe flare-up in his pain. He is quite miserable
with back and bilateral leg pain, it is equal on both sides. He is going to be going on a long flight later this
week. He would like to ahead with an epidural Will see her back as needed.

INFORMED CONSENT DISCUSSION

Risks, benefits, and alternatives were discussed with the patient. Risks include bleeding, infection, nerve
damage, allergic reaction, steroid side effects, and post dual puncture headache.

patient understands the risks and wishes to proceed

TECHNICAL INFORAMTION

The patients identify and the procedure to be performed were confirmed by the procedure nurse. The
apt was taken to the procedure room and placed in a prone position. The back was prepped and draped
in a usual sterile fashion. A 22-gauge Tuohy needle was inserted under fluoroscopic guidance into the
right L5-S1 interlaminar space. Using a loss of resistance technique, the epidural space was identified.
Nonionic intravascular injection of contrast. Depo Medrol 80 mg and 2 cc of 1% Lidocaine were injected.
The needle was then withdrawn.

CONCLUSIONS

1. Successful injection of local anesthetic and steroid at the right LS-s1 interlaminar epidural space.

2. There were no complications