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Consent – Lumbar Discography / Analgesic Intradiscal InjectionWesley2018-12-24T09:33:55-07:00

Injection Consent - DISCOGRAPHY / ANALGESIC INTRADISCAL INJECTION

  • If you would like this consent emailed to you, please enter your email address.
  • I authorize the following procedure: DISCOGRAPHY / ANALGESIC INTRADISCAL INJECTION THIS PROCEDURE INVOLVES THE INJECTION OF XRAY DYE AND MEDICATIONS SUCH AS STEROIDS AND LOCAL (State Nature and Extent of Procedure ANESTHETICS INTO THE INTO THE INTERVERTEBRAL DISC OF YOUR LUMBAR BETWEEN VERTEBRAL SEGMENTS AT THE LEVEL OF (Level) To be performed by Dr. Kai-Uwe Lewandrowski and associates and assistants of his/her choice.

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

    BENEFITS RISKS ALTERNATIVES
    INTRADISCAL DISCOGRAPHY may help identify the source of your back pain and leg pain by either stimulating the diseased level by provoking pain, or by reducing your pain. ADDITIONAL BENEFITS include increased likelihood of correct
    diagnosis and/or decrease or elimination of your pain.    		 • Blood loss. Blood loss from DISCOGRAPHY AND INTRADISCAL INJECTION 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 or identify the source of your pain. Your physician will do everything possible to give you the best results. Even so, the procedure may not relieve all your symptoms or perhaps even worsen
    them.
    .    		 DISCOGRAPHY WITH INTRADISCAL INJECTION is usually done to identify the source of your pain. Other procedures and imaging studies
    may also aid in the diagnosis. These can include:
    • Radiographic Studies (MRI, CT, Xrays)
    • Epidural Steroid Injections
    • Response to physical therapy
    • Watching and waiting If you feel your symptoms are not severe enough to have the procedure, tell your doctor. He or she will respect your decision.
  • Patient Information: Lumbar Discography With Intradiscal Injection: Your referring physician has requested that you have a lumbar discography with injection of xray dye and medications, such as steroids or local anesthetics. 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. A lumbar discography with intradiscal injection is an invasive procedure with some uncommon risks and side effects, so you will need to give informed consent. Local anesthesia (numbing medicine) will be injected underneath your skin. A needle will be placed with fluoroscopic (x-ray) guidance into the spine bypassing the fibrous fluid-containing sac that contains the lumbar nerve roots directly into a diseased lumbar intervertebral disc. A small of contrast (x-ray dye) will be injected to confirm correct needle placement and to provoke pain. Then an injection of local anesthetic medication and / or 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 after the procedure. Most complications of lumbar discography with intradiscal injection 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.
  • What is discography with intradiscal injection? Discography is a diagnostic procedure in which x-ray dye (x-ray contrast) is injected into the discs of the spine. After the x-ray dye is injected, a x-ray (called a "discogram") is taken of the discs. The discogram may be normal or may show tears (fissures) in the lining of the disc. The results of discography are used to plan surgery or other treatments. The intent of this procedure is to identify the source of your pain. It is a diagnostic procedure and will most likely not reduce inflammation or relieve pain. In fact, you may have more pain. The injection is performed by a specialist in interventional pain management.
  • How do I know if my pain is from a damaged disc? With age or from an injury, the wall of the spinal discs can get cracks or tears (fissures). This condition is call Internal Disc Disruption or Degenerative Disc Disease. Also, the wall of the disc can weaken and bulge out (a herniated disc). When the disc causes pain, the pain is usually felt as a deep, aching pain in the back and sometimes in the buttocks and into the thigh. However, pain from facet joints in the back and from the sacroiliac joints (SI joints) can be in the same location and feel the same. The best way to tell if the pain is from a damaged disc is with discography.
  • How is discography performed? The procedure is done in the Operating Room with fluoroscopic (x-ray) guidance. For lumbar discography (discs in the low back), it is done with you lying on your stomach. For cervical discography (discs in the neck), it is usually done with you lying on your back. There will be a nurse present during the procedure to monitor you and. You are watched closel. The skin over the injection site(s) is cleaned with an antiseptic solution and then the injections are carried out. After the injection, you are placed on your back or on your side.
  • What will I feel during the injection? When a normal disc is injected, you will feel a sense of pressure, but not pain. When an abnormal disc is injected, you will feel pain. It is important to try to tell if the pain you are feeling is your usual pain or different. With each disc injected, you will be asked if it is painful, where you feel the pain and whether it is in the same area as your usual pain.
  • 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.
  • How many levels will be injected? Based on your symptoms and your MRI, we will identify which discs we suspect are causing your pain. These discs will be injected. In addition, we inject a normal disc to serve as a reference point.
  • How long does the discography take? Discography takes about 30 to 45 minutes, depending on how many levels are injected.
  • What is actually injected? The injection consists of x-ray dye (x-ray contrast). It is usually mixed with some antibiotics to prevent infection. You may also have an injection of local anesthetic and steroids to aid in the diagnostic procedure.
  • Will the injection hurt? The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"), so there is some discomfort involved. However, your doctor will numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the disc. Some patients may require sedation and analgesia, which makes the procedure easy to tolerate. You may have a flare-up of your back pain after the injection, but this gets better in a day or two and can usually be managed with ice packs and oral pain medication.
  • Will I be “put out” for the procedure? No. This procedure is done under local anesthesia. Injection of a medicine like Novocaine-Lidocaine is performed to numb the skin. If you require additional sedation and analgesia to help you relax and make the procedure easier to tolerate please let your doctor know. The amount of sedation given depends upon the patient. You can be sleepy while the needles are placed, but during the discogram injections, you need to be awake enough to tell the doctor what you are feeling.
  • Will I feel better after the procedure? No. Discography does not treat your condition. It is a diagnostic test that allows your doctors to plan your therapy. You may feel temporary relief if you had an analgesic injection into the diseased disc.
  • What should I do after the procedure? You will need a ride home. We advise the patients to take it easy for a day or so after the procedure. You may need to apply ice to the affected area for 20-30 minutes at a time for the next day. Perform the activities as tolerated by you. 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.
  • What are the risks of the injection? Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain -, which is temporary. Sometimes, the discogram needle brushes past a nerve root and the nerve root is irritated. This pain almost always gets better quickly. The other risks involve infection, bleeding, and worsening of symptoms. Fortunately, the serious side effects and complications are uncommon.
  • What are the 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 Discography and Intradiscal Injection has an extremely good safety profile, and serious complications are quite rare. Just like any other medical procedure, there are potential complications associated with the procedure. 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.
  • When can I go back to work? We usually recommend taking 2-3 days off work after the injection.
  • 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.
  • 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.
  • 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.
  • 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.
  • Infection: Any needle passing through the skin can introduce infection, which in an epidural injection would be meningitis. In case of an intradiscal injection it would be discitis. This is an extremely rare complication and sterile technique will be used. However, you may need to be treated surgically (removal of the infected tissue), and prolonged intravenous antibiotics for several weeks to months, and in rare cases for lifetime.
  • 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.
  • 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.)
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.

  • 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.

    I have been given an opportunity to ask questions about my condition, alternative forms of treatment, the risks of treatment versus non-treatment, the procedure(s) to be used and the risks and hazards involved, and I feel that I have sufficient information to give this informed consent. I certify that this document has been read by me, or explained to me, that I understand its contents and that a copy of this document has been made available to me.
  • MM slash DD slash YYYY
  • Clear 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.

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