Consent – Intra-articular Hip Injection – Center for Advanced Spine Care of Southern Arizona

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An intra-articular hip injection is a procedure used to treat hip and groin pain. Usually this pain comes from inflammation (swelling) that happens from daily “wear and tear.” In some patients, the pain is from an injury or a birth defect.

During the procedure, a mixture of a local anesthetic and a steroid is injected into the hip. The local anesthetic will numb the area, and the steroid may help lower the swelling. This should reduce your pain and improve the motion in your hip.

Preparing for the procedure
Once your procedure is scheduled, we will give you instructions on how to prepare. It is very important for your safety to tell us if you:
• Take a blood thinner (for example, warfarin/Coumadin, Lovenox or Plavix);
• Take anything that contains aspirin or an anti-inflammatory drug, such as ibuprofen (for example, Advil or Motrin) or naproxen (for example, Aleve);
• Have a condition that prevents your blood from clotting normally; or
• Have any allergies to latex, local anesthetics or contrast (X-ray dye).

Please plan to have someone drive you home after your procedure. If you do not, your procedure may need to be rescheduled.

What to expect
The procedure takes about 15–20 minutes. You will be awake during the procedure and ask questions at any time. Before you leave, we will give you instructions on how to care for
yourself at home.

After the procedure
• You will want to be as active as possible and do the activities that usually cause pain in your hip and/or groin after the procedure. This will help your doctor know whether your
pain is caused by your hip.
• Keep track of your pain for 4 hours after your procedure. Your doctor will give you a diary to write down your pain levels and activities.
• You may feel sore for a few days after the procedure. Use an ice pack at least 3–4 times a day to feel more comfortable.
• The local anesthetic will wear off in about 4 hours. At that time, your usual level of pain may return until the steroid starts working. This can take up to 2 weeks. Keep taking pain medication, as prescribed, if you need it.
• Pain relief from a hip injection usually will last for several months, but this may vary from patient to patient. You may have 3–4 steroid injections a year. If you get no relief from the injection, we will continue to work with you to find the source of your pain and explore other treatment options.

Side

Left
Right

Agree to all?

Yes

Common Side Effects: Side effects from this procedure are rare. The most common side effect is pain where you were injected. Others include bleeding and infection.

Accept Common Side Effects*

I accept

Additional Procedures: I consent to the performance of operation(s) or procedure(s) in addition to or different from those now contemplated, arising from presently unforeseen conditions, which the above named doctor or his/her associates or assistants may consider necessary or advisable in the course of the procedure.

Accept Additional Procedures*

I accept

Results Not Guaranteed: I understand that in some cases the operation may not be successful, and that I could be no better or even worse than I am now. Furthermore, I understand that no guarantee or assurance has been made as to the results of the procedure(s) and that it may not cure the condition. It may, however, deliver diagnostic information.

Accept Results Not Guaranteed*

I accept

Anesthesia: The administration of anesthesia also involves serious risks, most importantly, a rare risk of reaction to the medications causing death. I understand that in the event that anesthesia is administered by an anesthesiologist, then I should discuss the specific risk with the anesthesiologist providing the service. I consent to the use of such anesthetics as may be considered necessary by the person responsible for these services.

Accept Anesthesia*

I accept

Bleeding: As with all needle procedures, bleeding can occur. As long as you have no bleeding tendency and are not on any blood-thinners such as Coumadin, bleeding complications are extremely rare. However, patients have rarely had to undergo emergency surgery to relieve pressure on the nerve roots and spinal cord because of bleeding after needle procedures like epidural steroid injections. The procedure may require blood transfusion during or after the operation. Blood replacement may be autologous (self-given), or homologous (from someone else), and the risks of that have been explained to me.

Accept Bleeding*

I accept

Infection: Any needle passing through the skin can introduce infection, which in an epidural injection would be meningitis. This is an extremely rare complication and sterile technique will be used.

Accept Infection*

I accept

Spinal Headaches: This is a rare complication that may occur if a small hole is made in the fibrous sac and does not close up after the needle puncture. These small holes are only made in less than 1% of epidural injections and usually heal on their own. The spinal fluid inside can leak out, and when severe, the brain loses the cushioning effect of the fluid, which causes a severe headache when you sit or stand. These types of headaches occur typically about 2-3 days after the procedure and are positional - they come on when you sit or stand and go away when you lie down. If you do develop a spinal headache, it is OK to treat yourself. As long as you do not feel ill and have no fever and the headache goes away when you lay down, you may treat yourself with 24 hours of bed rest with bathroom privileges while drinking plenty of fluids. This almost always works. If it does not, contact the radiologist who performed the procedure or your referring physician. A procedure (called an epidural blood patch) can be performed in the hospital that has a very high success rate in treating spinal headaches.

Accept Spinal Headaches*

I accept

Steroid Side Effects: Epidural steroids may rarely produce unwanted side effects. Some of these potential side effects include increased blood sugar or hyperglycemia (especially in diabetic patients), fluid retention, elevated blood pressure, and transient redness or facial flushing. (Side effects from steroids may be common if they are taken daily over a length of time, rather than as an isolated epidural injection.)

Accept Steroid Side Effects*

I accept

Patient Compliance: I understand that my continuing of smoking after surgery or non-compliance with my physician’s advice as to weight-bearing status, restrictions & limitations, or specific instructions for recovery and rehabilitation may have deleterious effects on clinical results.

Accept Patient Compliance*

I accept

Medical Education & Research: I consent to the photographing or televising of the procedures to be performed, including appropriate portions of my body, for medical, scientific or educational purposes, providing my identity is not revealed by the pictures or by descriptive text accompanying them.

Accept Medical Education & Research*

I accept

Healthcare Personnel In Training: I consent to the admittance of observers to the operating room/procedure room for the purpose of advancing medical education. I further understand that some services relating to the operation/procedure may be provided by the healthcare personnel in training, residents and medical students under the supervision of the surgeon, anesthesiologist or hospital employees.

Accept Healthcare Personnel In Training*

I accept

Allergic Reaction: The use of any medication, including x-ray contrast, has the possibility of producing an allergic reaction. Please inform your physician of all of your known medical allergies before the procedure. If you have any questions, please feel free to ask the physician performing the procedure prior to signing the consent form.

Accept Allergic Reaction*

I accept

Radiation & Contrast: I consent to the use of x-rays, fluoroscopy, and contrast media, if necessary for radiological purposes and understand that this may have some undesirable side effects.

Accept Radiation & Contrast*

I accept

Patient’s Consent: I confirm, that my physician has explained to me the nature, purpose and possible consequences of the operation/procedure stated on this form, as well as the risk involved, the possibility of complications and the possible alternative methods of treatment; that I understand that the explanation I have received is not exhaustive and that other, more remote risks and consequences may arise; that I have been advised that a more detailed and complete explanation of any of the foregoing matters will be given to me if I so desire; that I do not desire such further explanation; and that I acknowledge that I have received no guarantees or assurances from anyone as to the results that may be obtained.

Accept Patient’s Consent*

I accept

Dispute Resolution: I agree and consent to resolve any dispute(s) that may arise out of my medical treatment(s) by physicians at the Center for Advanced Spinal Surgery of Southern Arizona via mediation by filing the case with the American Arbitration Association. I understand that this does not apply to any billing or collection related disputes for services provided to me.

Accept Dispute Resolution*

I accept

Disclosure On The Impact Of Health Care Reform On Your Care

I hereby ACKNOWLEDGE that my doctor will make every attempt to deliver the best care possible in the context of the dynamically changing health care environment. where there is an increasing amount of regulation and rules as to appropriateness and medical necessity of procedures and surgeries. In fact, your doctor is subject to such Medical Necessity and Appropriateness of Procedure Rules imposed by insurance companies, hospitals and surgery centers, where providers at the Center For Advanced Spine Care are currently performing procedures and surgeries at. As a result, the treatment recommendation that your doctor/surgeon may make could be affected by these rules and may not be necessarily the most appropriate or preferred treatment in his or her clinical judgement. In addition, procedures and surgeries may not be authorized and your doctor may simply not be able to perform certain procedures on you. With the transition of our local health care system from a Clinical Guidelines based system to a Rules based system, your doctor may not be able to provide the preferred recommended care given those newly imposed constraints.

IF YOU HAVE ANY QUESTIONS AS TO THE RISK OR HAZARDS OF THE PROPOSED SURGERY/PROCEDURE(S) OR ANY QUESTIONS CONCERNING THEM ASK YOUR PHYSICIAN BEFORE SIGNING THIS FORM.

Today's Date

Signature*

I HAVE EXPLAINED THE RISK/BENEFITS/ALTERNATIVES OF THIS PROCEDURE TO THE PATIENT/REPRESENTATIVE WHO HAS INDICATED UNDERSTANDING THEREOF AND HAS CONSENTED TO ITS PERFORMANCE.

Injection Consent - Intra-articular Hip Injection