Example of a note from fellowship with way more detail than I use now:
Spinal Catheter Placement Tunneled OR Procedure Note
Pre-Op Diagnosis: Lower extremity spasticity, spastic paraparesis, chronic pain, primary lateral sclerosis, hip pain
Post-Op Diagnosis: Lower extremity spasticity, spastic paraparesis chronic pain, primary lateral sclerosis, hip pain
Procedures: Tunneled intrathecal catheter
Anesthesia: MAC
IV Fluid: 700 mls
EBL: 5 mls
Specimens: none
Drains: none
Complications: none
Disposition: PACU then floor
Condition: Stable
Periop antibiotics: Ancef 2 grams/ Gentamicin 100 mg
Time of Last Dose of Periop Antibiotics: 0806
Post op antibiotic plan: Ancef 1g q8 hours x 5 days (duration of stay and hardware in)
Indication for antibiotics (if longer than 24 hours total): hardware in communication with intrathecal space
Notes: Used 18 gauge 7" touhy needle to access intrathecal space at L2-L3 interlaminar space via a left paramedian approach. Arrow Flextip wire reinforced, styleted 20 g catheter utilized.
Started intrathecal baclofen 5mcg/ml at an initial rate of 0.2ml/hr = 24mcg/day after a 10mcg bolus at 10:00am.
PROCEDURE:
Patient was identified in holding area. The risks and benefits of the procedure as well as indications, contraindications, side effects were again discussed with the patient and his wife. All questions were answered and updated history and physical was obtained. Written, informed consent was obtained and filed in the chart.
Patient was transferred to the OR and placed into right lateral decubitus position. All pressure points were checked and padded. Routine ASA monitors were applied. Antibiotics were administered within half hour of surgical incision time. Time outs performed.
Fluoroscopy was utilized to delineate the anatomy of the thoracolumbar spine. Both AP and lateral views were obtained. Local anesthetic of bupivacaine 0.25% was infiltrated in the intended direction of spinal needle placement, starting at the left L4 pedicle and along a tract toward the midline L2-3 interspace just caudad to the L2 spinous process for a total of 10ml.
Next, a 15 blade was used to incise the skin over the left L4 pedicle and an 18 gauge, 7 inch Touhy needle was inserted and advanced via a left paramedian approach until contacting spinous prcoess. Needle was adjusted and advanced via an L2-3 interlaminar approach into the intrathecal space. Bevel tip was oriented in parallel fashion to longitudinal fibers of the dura in order to minimize trauma. Positive CSF was obtained, clear and fluent, and then bevel was redirected in cranial direction. Needle placement was confirmed via AP and lateral fluoroscopic images. Then the stylete was removed and an Arrow Flextip wire reinforced, styleted 20 g catheter was advanced through the spinal needle in a cephalad direction. Intermittent AP fluoroscopy was utilized while advancing the spinal catheter to the top of the T9 vertebral level and then withdrawn until the tip was at the level of the top of T10 vertebral body. Then the stylet was removed and a sterile connector was applied and a 3cc syringe was attached to the connector and after aspiration of CSF the patient then received a subarachnoid injection of 2 mL diluted Omnipaque 180 mixed with 1 mL the patient's own CSF, a total of 3 mL revealing a myelogram. Then 3ml of sterile, preservative free saline was injected to replete lost CSF in order to minimize risk of spinal headache. The needle was carefully backed out of the subarachnoid space while maintaining constant placement of the indwelling subarachnoid catheter.
Next, our attention was turned to tunneling the catheter. The the skin along the tract was anesthestized with another 13ml of 0.25% bupivicaine. Then a 17 gauge, 6 inch Touhy type needle was used as a tunneling device. The stylet was removed and advanced from the midline site and passed subcutaneously in a lateral direction to the left and exited in the left flank. After removing surrounding Ioban, the needle was placed over the tip of the stylet and pulled back through to midline. Then the intrathecal needle was carefully backed out of the skin while maintaining constant placement of the indwelling subarachnoid catheter. Repeat flouroscopic views after injecting another 0.75ml of contrast to make catheter more radiopaque revealed it had migrated caudally and was overlying the top of th T11 vertebral body, corresponding to our intended level. The end of the catheter was placed into the tunneling needle and advanced and then the needle was withdrawn with the catheter exiting the left flank. The catheter was withdrawn until it was no longer protruding from the midline incision. Then the sterile connector and filter were replaced on the end of the catheter. Skin was approximated midline and covered with dermabond to close the skin and then dermabond was placed along the catheter exit site and along the course of the catheter coil to prevent bacterial seeding along catheter exit site and to keep the catheter in place. These areas were covered with several tegaderms to further affix the catheter and to keep the site sterile. The patient was transferred back to the stretcher and then transferred to the PACU for recovery.
While in the recovery room, the patient was noted to be entirely stable and alert. The intrathecal pump solution was programmed into the patient's intrathecal pump. After priming the tubing and filter with baclofen 5mcg/ml, the patient received a 10mcg bolus at 10:00am followed by a simple continuous infusion with initial rate of 0.2ml/hr = 24mcg/day.
