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Interventional Spine Procedures: A Case-based Approach
Alexander R Vaccaro, Jeremy Simon, Mitchell Freedman, Michael J Mehnert
1:
Basic Principles of Fluoroscopically-guided Procedures
INTRODUCTION
STERILE PREPARATION
NEEDLE-DRIVING
FLUOROSCOPY
Parallax
CONTRAST
ANTICOAGULANTS
Protocol for Holding Anticoagulants25–27
2:
Lumbar Disc Herniation with Radiculopathy: Selective Spinal Nerve Injection
CHIEF COMPLAINT
HISTORY OF PRESENTING ILLNESS
PAST MEDICAL/SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING STUDIES
ELECTRODIAGNOSTIC STUDIES
DIAGNOSIS
TREATMENT
SUMMARY
3:
Lumbar Disc Herniation with Radiculopathy: Lumbar Transforaminal Epidural Steroid Injection
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
REVIEW OF SYSTEMS
PAST MEDICAL HISTORY
SURGICAL HISTORY
MEDICATIONS
ALLERGIES
FAMILY HISTORY
SOCIAL HISTORY
PHYSICAL EXAMINATION
IMAGING
DIAGNOSIS
NONINTERVENTIONAL TREATMENT OPTIONS
INTERVENTIONAL OPTIONS
Lumbar Transforaminal Epidural Steroid Injection (LTFESI)
PATIENT DISCUSSION
PLAN
Left L5-S1 Transforaminal Epidural Steroid Injection
4:
Lumbar Spinal Stenosis with Radiculopathy
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
DIAGNOSIS
Discussion
TREATMENT OPTIONS
Lumbar Interlaminar Injections
COMPLICATIONS/PITFALLS
Subarachnoid Injection
Epidural Abscess
Epidural Hematoma
Intravascular Injection
Anatomical
5:
Coccygodynia
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL/SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
COCCYGODYNIA
TREATMENT OPTIONS
INTERVENTIONAL OPTIONS
PLAN
PROCEDURE
Indications
Preoperative Diagnosis
Postoperative Diagnosis
Procedure Performed
CONCERNS, PITFALLS AND TIPS
6:
Lumbar Facet Syndrome
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING
DIAGNOSIS
TREATMENT OPTIONS
INTERVENTIONAL OPTIONS
SAMPLE PROCEDURE NOTES
Lumbar Intra-articular Zygapophysial Joint Injection
Lumbar Medial Branch Block (Zygapophysial Joint Nerve Block)
7:
Sacroiliac Joint Pain
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
General Appearance
IMAGING
DIAGNOSIS
Sacroiliac Joint Pain
TREATMENT OPTIONS
INTERVENTIONAL OPTIONS
Classical Sacroiliac Joint Infiltration Technique
Radiofrequency Treatment of the Sacroiliac Joint
Radiofrequency Technique
8:
Cervical Disc Herniation with Radiculopathy
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
FAMILY HISTORY
MEDICATIONS
ALLERGIES
SOCIAL HISTORY
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
Vital Signs
General Appearance
Reflexes
IMAGING STUDIES
X-Rays
Magnetic Resonance Imaging
DIAGNOSIS
TREATMENT OPTIONS
INDICATIONS
Cervical Epidural Steroid Injection: Transforaminal Approach
DISCUSSION
CLINICAL OUTCOME
9:
Cervical Disc Herniation without Radiculopathy
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL/SURGICAL HISTORY
FAMILY HISTORY
SOCIAL HISTORY
MEDICATIONS
ALLERGIES
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
General Appearance
IMAGING
DIAGNOSIS
TREATMENT OPTIONS
INTERVENTIONAL OPTIONS
10:
Cervical Facet Syndrome
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING
DIAGNOSIS
Treatment Options
Interventional Options
Cervical Intra-articular Facet Injection
Cervical Medial Branch Block
Cervical Medial Branch Radiofrequency Ablation
11:
Hip Pain
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
General Appearance
IMAGING
DIAGNOSIS
Treatment Options
12:
Complex Regional Pain Syndrome—Lower Extremity
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
TREATMENTS TO DATE
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING
DIAGNOSIS
Complex Regional Pain Syndrome
TREATMENT OPTIONS
PLAN
SAMPLE DICTATION
13:
Complex Regional Pain Syndrome—Upper Limb
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
TREATMENTS TO DATE
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING
Three-Phase Bone Scan, Right Upper Limb
Right Forearm, Wrist and Hand X-rays
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Complex Regional Pain Syndrome
TREATMENT OPTIONS
PLAN
PROCEDURE NOTE
INDICATIONS
PREOPERATIVE DIAGNOSIS
POSTOPERATIVE DIAGNOSIS
PROCEDURE PERFORMED
STELLATE GANGLION BLOCK (FIGS 13.2 AND 13.3)
14:
Dural Puncture Headache
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
General Appearance
IMAGING
DIAGNOSIS
DISCUSSION
TREATMENT
Sample Dictation
15:
Adverse Reactions to Medications
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
General Appearance
Neurological
IMAGING
DIAGNOSIS
Plan
Method of Procedure
ADDITIONAL DIAGNOSIS
Plan
DISCUSSION
16:
Discogenic Low Back Pain/ Lumbar Disc Herniation without Radiculopathy
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
General Appearance
Inspection
Gait
Range of Motion
Neurological
IMAGING
Lumbar Spine X-Rays
Lumbar Spine Magnetic Resonance Imaging without Gadolinium
DIAGNOSIS
Plan
Lumbar Provocative Discography Method of Procedure
Discography Results
Discography Findings
Post-Discography Computed Tomography
Discography Impression
DISCUSSION
TREATMENT OPTIONS
SUMMARY
17:
Thoracic Facet Pain
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
REVIEW OF SYSTEMS
FAMILY HISTORY
SOCIAL HISTORY
CURRENT MEDICATIONS
ALLERGIES
PHYSICAL EXAMINATION
IMAGING
X-Rays
Magnetic Resonance Imaging
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Thoracic Zygapophysial Joint Pain
TREATMENT OPTIONS
Interventional Options
Plan/Treatment Course
Tricks and Tips
Procedure Note—Thoracic Intra-articular Zygapophysial Joint Injection
Procedure
Indications
Preoperative Diagnosis
Postoperative Diagnosis
Procedure Performed
Procedure Note—Thoracic Medial Branch Block
Procedure
Indications
Preoperative Diagnosis
Postoperative Diagnosis
Procedure Performed
Procedure Note—Radiofrequency Neurotomy of Thoracic Medial Branches
Procedure
Indications
Preoperative Diagnosis
Postoperative Diagnosis
Procedure Performed
18:
Thoracic Disc Herniation
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
PAST MEDICAL HISTORY
ALLERGIES
FAMILY HISTORY
SOCIAL HISTORY
MEDICATION HISTORY
REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
Vital Signs
Neurological
Thoracic and Lumbar Spine
Inspection
Palpation
Range of Motion
Tone
Stability
Special
ASSESSMENT WITH DIFFERENTIAL DIAGNOSIS
Mid-Back Pain Radiating into Ribs
Treatment Plan
BACKGROUND
INDICATIONS FOR INJECTION
TREATMENT ALTERNATIVES
CONTRAINDICATIONS
THORACIC TRANSFORAMINAL EPIDURAL STEROID INJECTION
Preparation
EQUIPMENT AND MEDICATIONS
TECHNIQUE: OBLIQUE SUBPEDICULAR TRANSFORAMINAL APPROACH
OTHER TECHNIQUES
COMPLICATIONS
EVIDENCE TO SUPPORT THE PROCEDURE
Coding
INDEX
TOC
Index
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