Consent – Injection SI Block – Center for Advanced Spine Care of Southern Arizona

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I authorize the following procedure: SI BLOCK THIS PROCEDURE INVOLVES THE INJECTION OF STEROIDS IN THE POSTERIOR ELEMENTS OF YOUR LUMBAR SPINE TO REDUCE PAIN DUE TO ARTHRITIC FACET JOINTS BETWEEN VERTEBRAL SEGMENT AND (area indicated below) to be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice

With Facet Block

Yes

Dual Sternum

Levels

Cervical
Lumbar
Thoracic

Side

Left
Right
Bi-lateral

Cervical

Lumbar

Thoracic

The benefits, risks, and alternatives to this procedure are list in the following table:

BENEFITS

RISKS

ALTERNATIVES

SI BLOCK
may relieve back pain, leg pain, and numbness or weakness caused by a pinched nerve root.

ADDITIONAL BENEFITS
include increased likelihood of correct diagnosis and/or decrease or elimination of your pain.

• Blood loss. Blood loss from SI BLOCK (LUMBAR FACET & SI BLOCK) is usually small. But as with any procedure, there is always the potential for bleeding, bruising or even major life-threatening blood loss. You should not be taking or be on Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox.
• Dysthetic (stabbing, burning) leg pain (fewer than 5 in 100 cases).
• Infection (fewer than 1 in 100 cases). Even with antibiotics and careful sterile techniques, there is still a very small risk of developing a wound infection.
• Damage to spinal nerves (fewer than 1 in 10,000 cases). If nerves are damaged, you could be left with permanent pain, numbness or weakness in your arms (as a result of prolonged position) or your legs, such as foot drop.
• Scar tissue formation (fewer than 5 in 100 cases) requiring further intervention such as additional procedures or surgery
• Failure to relieve symptoms. Your physician will do everything possible to give you the best results. Even so, the procedure may not relieve all your symptoms.

SI BLOCK is usually done
after nonsurgical treatment
options have failed. These can
include:

• Medications
• Physical therapy
• Traction
• Watching and waiting

If you feel your symptoms are
not severe enough to have
surgery, tell your doctor. He or
she will respect your decision.

Patient Information:SI Block. Your referring physician has requested that you have an lumbar facet & medial branch block. The following is a description of the procedure and a description of the potential complications, so that you can give informed consent to have the procedure. An lumbar facet & medial branch blockis an invasive procedure with some uncommon risks, so you will need to give informed consent. Local anesthlumbar facet & medial branch blocka (numbing medicine) will be injected underneath your skin. A needle will be placed with fluoroscopic (x-ray) guidance into the spine along the fibrous fluid-containing sac that contains the lumbar nerve roots. A small of contrast (x-ray dye) will be injected to confirm correct needle placement. Then an injection of steroids will be made into the same location. You will then be monitored for potential complications for a short time after the procedure (usually about 30 minutes) until you are discharged. You will be able to eat and drink as well as use the bathroom while in the hospital after the procedure. Most complications of lumbar facet & medial branch blocks are rare and the procedure is very safe. You need to know the potential complications, which include:

In addition to the risks outlined below this procedure carries the specific risks of increased pain (more pain than you had before), inflammatory reaction possibly resulting in scarring of nerves causing more pain, infection, bleeding, bruising, allergic reaction, nerve damage involving temporary or permanent pain/numbness or weakness, low blood pressure, weakness or numbness of arm or leg, headache requiring epidural blood patch and very rarely paralysis.

Please read and acknowledge every paragraph with a check mark.

Agree to all?

Yes

What is a SI Block? An Lumbar facet & medial branch block (LUMBAR FACET & SI BLOCK) is a simple, safe, and effective non-surgical treatment that involves the injection of a steroid medication similar to cortisone into the Epidural Space of the spine. Instead of the epidural space the medical is injection into the facet joint iteselt. The intent of this procedure is to reduce inflammation and therefore relieve pain. Performed by an interventional pain management, LUMBAR FACET & SI BLOCK is a minimally invasive technique used to relieve a variety of painful conditions, including chronic pain anywhere in the spine.

Accept What is a Lumbar facet & SI block?*

I accept

How is the Injection done? Although there are different techniques used for Lumbar facet & SI block, the most common technique employed by interventional pain management specialists now is with X-Ray guidance (fluoroscopy), usually with the patient lying on his or her stomach. Dr. Lewandrowski uses fluoroscopy for all of his LUMBAR FACET & SI BLOCK procedures. The injection is performed under local anesthesia and, on occasion, with intravenous sedation. Patients are not deeply sedated or completely asleep for this procedure because it is unnecessary and unsafe to do so. The procedure usually takes no more than 5-10 minutes, followed by a brief 15-20 minute recovery before discharge home.

Accept How is the Injection done?*

I accept

What types of conditions will respond to an LUMBAR FACET & SI BLOCK: For over forty years, LUMBAR FACET & SI BLOCK has been used to effectively treat chronic neck and back pain as well as a variety of other conditions. The most common diagnoses treated with LUMBAR FACET & SI BLOCK include herniated or bulging discs, spinal stenosis, and recurrent pain following spine surgery. Other conditions that may also respond to LUMBAR FACET & SI BLOCK include spondylolisthesis (slippage of the vertebral column) and post-herpetic neuralgia (pain after shingles).

Accept types of conditions*

I accept

Does the injection hurt? The injection of local anesthetic (numbing medicine) at the beginning of the procedure may sting some, but LUMBAR FACET & SI BLOCK is an otherwise routine procedure that is extremely well tolerated by patients ranging in age from the mid-teens to well over ninety years old. If you are anxious or concerned about pain during the procedure, please discuss with Dr. Lewandrowski the possibility for your receiving intravenous sedation.

Accept Does the injection hurt?*

I accept

What should I do to prepare for the injection? If you are taking any type of medication that can thin the blood and cause excessive bleeding, you should discuss with your doctors whether to discontinue this medication prior to the procedure. These anticoagulant meds are usually prescribed to protect a patient against stroke, heart attack, or other vascular occlusion event. Therefore the decision to discontinue one of these medications is not made by the pain management physician but rather by the primary care or specialty physician (cardiologist) who prescribes and manages that medication. Examples of medications that could promote surgical bleeding include Coumadin, Plavix, Aggrenox, Pletal, Ticlid, and Lovenox.

Accept What should I do to prepare for the injection?*

I accept

What should I expect after the injection: You may notice some reduction in your pain for the first 1-2 hours after the injection if local anesthetic is injected with the steroid. When this anesthetic wears off, your pain will return as it was before the procedure. Although pain relief with LUMBAR FACET & SI BLOCK generally occurs within 3 - 5 days, some patients experience improvement before or after this time period. Diabetic patients should be on the alert for a rise in blood sugar during the first few days after injection and must monitor blood sugar accordingly.

Accept What should I expect after the injection*

I accept

What should I do after my injection: Following discharge home, you should plan on simple rest and relaxation. If you have pain at the injection site, application of an ice pack to this area should be helpful. If you receive intravenous sedation, you should not drive a car for at least eight hours. Patients are generally advised to go home and not return to work after this type of injection. Most people do return to work the next day.

Accept What should I do after my injection*

I accept

Common Side Effects: Minor side effects from the injected medications are not uncommon and can include nausea, itching, rash, facial flushing and sweating among other things. Some patients notice a mild increase or worsening of their pain for the first day or two after injection. Fortunately Lumbar facet & medial branch block has an extremely good safety profile, and serious complications are quite rare. Just like any other medical procedure, there are potential complications associated with LUMBAR FACET & SI BLOCK. Your physician will discuss these issues with you, and you will be asked to carefully read and sign a consent form before any procedure is performed.

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 anestheologist, then I should discuss the specific risk with the anestheologist 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 lumbar facet & medial branch blocks. 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 dural sack – a fibrous sac that houses the spinal nerves - 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, rlumbar facet & medial branch blockdents and medical students under the supervision of the surgeon, anestheologist 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 undesired 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 dlumbar facet & medial branch blockre; 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.

Consent – Injection SI Block

Injection Consent - SI BLOCK