Spine Pain Management Program

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Sara Hicks
5 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: Epidural Adhesiolysis Please check the indication (reason) for this procedure and complete the form below: Epidural Adhesiolysis with no indication Epidural Adhesiolysis for radiculopathy incapacitating or severe persistent radicular Pain Epidural Adhesiolysis for diagnosis or treatment of axial pain Epidural Adhesiolysis for management of spinal pain

2 Requested 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 Requested Procedure What is the primary spinal region involved? (choose only one) Cervical Thoracic Lumbosacral 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 Please indicate the severity of these symptoms Very mild Mild Moderate 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 Please indicate the severity of these neurologic signs Very mild Mild Moderate Severe Very severe Progressive Page: 01

3 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 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 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 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 Other 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 Other Medications Heat Ice Physical Modalities Massage Other Page: 02

4 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% Please assess the improvement in function noted since initiating primary/conservative care ne 1-10% 11-20% 21-30% Over 30% Prior Care Has an epidural adhesiolysis previously been performed for this spine condition? Please indicate the date on which an epidural adhesiolysis was last performed? M M D D C C Y Y Please indicate the spinal levels in which an epidural adhesiolysis was last performed. C T L S Please assess the overall improvement in symptoms following your last epidural adhesiolysis. 0% 1-10% 11-20% Please assess the overall improvement in function following your last epidural adhesiolysis. 0% 1-10% 11-20% Specify Prior Epidural Injection Please assess how long the improvement in function lasted <24 hours 1-7 days 8-15 days days 30 days or more Contraindications Please indicate if there are any contraindications to this procedure Page: 03

5 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: Epidural Injection Please check the indication (reason)