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OPERATIVE REPORT

Patient Name:Genaro, Louis

Medical Record #:0001952

Date of Birth:08/20/1956

Date of Service:08/27/2012

Location:Journal Square Surgical Center, Jersey City, NJ.

PREOPERATIVE DIAGNOSIS:Left lumbar radiculopathy.

POSTOPERATIVE DIAGNOSIS:Left lumbar radiculopathy.

PROCEDURE:The patient was precertified for a left transforaminal epidural steroid injection at two levels, L4-L5 and L5-S1.

SURGEON:Alfred Mauro, M.D.

PROCEDURE IN DETAIL:

The patient was brought to the operating room. After risks and benefits were explained, consent was signed. IV access was established. The patient was placed in prone position, monitored by EKG, pulse oximeter, and blood pressure cuff, and given intravenous sedation by the anesthesiologist.

The lumbosacral area was prepped and draped using Betadine x3. After the initial prep, the L4-L5 and L5-S1 area was delineated using AP and oblique views. Local anesthetic was applied to the skin and subcutaneous tissue, 5 cc of 1% Xylocaine. A 22-gauge, 3½-inch needle was then placed in the foramen using verification of lateral views. Upon entering into the foramen, contrast was injected which outlined the nerve root and the epidural space. The patient was then given 40 mg of Depo-Medrol and 2 cc of 0.25% Marcaine. The needle was withdrawn. The second level of L5-S1 was then treated using the same approach, AP and oblique views, and local anesthetic of 5 cc of 1% Xylocaine injection anesthetizing the skin and subcutaneous tissue. A 22-gauge,
3½-inch needle was then guided into the epidural space. The epidural space was achieved using Isovue-300. The epidural spread was significant in the epidural space and the nerve root was also outlined at that level. The patient was then given 40 mg of Depo-Medrol and 2 cc of 0.25% Marcaine. The needle was withdrawn. The patient was brought to the recovery room in satisfactory condition and discharged with no apparent complications.

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Alfred Mauro, M.D.

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Genaro, Louis

August 27, 2012