Medical Specialty:
Pain Management

Sample Name: Botox Injection - Trigger Point


Description: Trigger point injections with Botox.
(Medical Transcription Sample Report)


PROCEDURE PERFORMED: Trigger point injections with Botox.

PREPROCEDURE DIAGNOSES:
1. Cervical spondylosis without myelopathy.
2. Myofascial pain syndrome.
3. Cervical dystonia.
4. Status post C5-6 anterior cervical fusion.
5. Multilevel degenerative disc disease.
6. Cervicogenic migraines.
7. Hypertension.
8. Hypothyroidism.

POSTPROCEDURE DIAGNOSES:
1. Cervical spondylosis without myelopathy.
2. Myofascial pain syndrome.
3. Cervical dystonia.
4. Status post C5-6 anterior cervical fusion.
5. Multilevel degenerative disc disease.
6. Cervicogenic migraines.
7. Hypertension.
8. Hypothyroidism.

COMPLICATIONS: None.

The risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained.

INDICATIONS: The patient is here today after establishing care at my new office. She is a long-term patient of mine at the Pain Management Clinic and has requested transference because of insurance reasons. Today, she is here for not only establishment of care, but continued management of her many neck-related complaints. Among these are spasms and ongoing pain for which she receives long-acting opioids. She states that she is in fact doing quite well since her cervical fusion. She is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of Avinza. She also is quite pleased with her other medication regimen which has been greatly simplified over the past year.

Other treatment modalities that have been helpful have included cervical epidural steroid injections. The patient is requesting that we schedule this as well, as the relief provided by that lasted anywhere from four to six months. I agree that because of intermittent radicular symptoms that this may be helpful particularly in light of her recent surgery. She does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination. I believe that in addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been oversedating as well as racked with other side effects.

DETAILS OF PROCEDURE: Alcohol prep and sterile technique were used. A total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature. The procedure was well tolerated.

TREATMENT PLAN:
1. The patient is tentatively scheduled for a cervical epidural steroid injection on March 14, 2005.
2. We will begin a weaning schedule for the patient's Avinza by decreasing in 60 mg intervals. The patient will have a target of 120 mg p.o. b.i.d., and then be reassessed. This is expected to occur after her cervical epidural steroid injection.

Keywords: pain management, trigger point, botox, cervical spondylosis, myofascial, cervical fusion, epidural, injection, levator scapulae, myelopathy, semispinalis musculature, splenius capitis, steroid, epidural steroid injections, cervical epidural, epidural steroid, steroid injections, cervical,