Spine Pain Management Program

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Darcy Blair
6 years ago
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1 Spine Pain Management Program Please complete the following information: Patient Name: Patient ID Number: Patient DOB: The procedure being requested is: Please check the indication (reason) for this procedure and complete the form below: Sacroiliac Rhizotomy with no indication

2 ed Procedure Please indicate the spinal levels on which this procedure will be performed C T L S History Please enter the date of onset for current episode M M D D C C Y Y What is the primary region of complaint Cervical Thoracic Lumbar Sacroiliac Please indicate on which side the injection will be performed Right Left Bilateral t applicable Indicate Signs and Syptoms Please indicate the symptom(s) associated with this spine condition Neck pain Mid-back pain Lumbosacral pain SI pain Radicular pain Neurogenic claudication Paresthesia ne of the above Please indicate the severity of these symptoms Severe Very severe Incapacitating Please assess the patient's overall physical function Very good Good Moderate Poor Very poor Indicate Neurologic Signs Please indicate the neurologic sign(s) associated with this spine condition Focal weakness Widespread weakness Atrophy Gait disturbance Pathologic reflex Clonus Spasticity ne of the above Please indicate the severity of these neurologic signs Severe Very severe Progressive Page: 01

3 Indicate Neurological Motor Deficits Please indicate if neurological motor deficits are present Please indicate the spinal nerve root(s) affected by the motor deficit C T L S Please indicate the severity of the motor deficit Severe Very severe Incapacitating Diagnostic Testing Please indicate the type of diagnostic testing previously performed for this condition CT MRI CT-Myelography X-rays Bending/Dynamic x-rays Bone scan/spect Needle EMG Nerve conduction testing H-reflex testing Sensory evoked potential Spinal biopsy Nerve root block ne of the above Please indicate the findings reported by this diagnostic testing Myelopathy Cauda equina Fracture Malignancy Infection Spondyloarthropathy Severe Instability Central stenosis Nerve root compression Spondylolisthesis Deformity Hardware failure Pseudoarthrosis Inconclusive ne of the above Please indicate the spinal levels on which these findings were reported C T L S Additional Information Please indicate if the clinical presentation is consistent with findings on diagnostic imaging Specify Prior/Conservative Care Please indicate the clinician(s) who delivered primary/conservative care for this spine condition PCP Medical Specialist Surgeon Physical Therapist Chiropractor Massage Therapist ne of the above Page: 02

4 Please indicate the primary/conservative care intervention(s) received for this spine condition NSAIDs n-opioid Analgesics Opioids Patient Education Supervised Exercise Spinal Manipulation Muscle Relaxants Medications Heat Ice Physical Modalities Massage ne of the above Please indicate the number of weeks of primary care received since the date of onset Please assess the improvement in symptoms noted since initiating primary/conservative care ne 1-10% 11-20% 21-30% 30% or more Please assess the improvement in function noted since initiating primary/conservative care ne 1-10% 11-20% 21-30% Over 30% Specify Sacroiliac Injections Please indicate if a sacroiliac injection was previously performed for this spine condition Please indicate on which side the sacroiliac injection was performed Right Left Bilateral t applicable Please indicate the date on which an sacroiliac injection was last performed M M D D C C Y Y Please indicate if the last sacroiliac injection was diagnostic(w/out steroid) or therapeutic(w/steroid) Diagnostic Therapeutic Please assess the overall improvement in symptoms after the last sacroiliac injection ne 1-15% 16-30% 31-50% 50-65% 66-80% % Page: 03

5 Please indicate the duration of improvement in symptoms lasted after the sacroiliac injection < 24 hours 1-7 days 8-15 days days 1-3 months 3-6 months 6-9 months more than 9 months Please indicate if a sacroiliac rhizotomy was previously performed for this spine condition Please assess the overall improvement in symptoms after the last sacroiliac rhizotomy ne 1-15% 16-30% 31-50% 50-65% 66-80% % Please assess the overall improvement in function after the last sacroiliac rhizotomy < 24 hours 1-7 days 8-15 days days 1-3 months 3-6 months 6-9 months more than 9 months Contraindications Please indicate if there are any contraindications to this procedure What are they? Page: 04

Spine Pain Management Program

Spine Pain Management Program Please complete the following information: Patient Name: Patient ID Number: Patient DOB: The procedure being requested: Facet Injection Please check the indication (reason)