Spine Radiofrequency Ablation Procedure Note

Date of Service: [Date of service]

Procedure Start Time: [Start time]

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Location: [Facility/Procedure suite]

Referring Clinician: [Referring clinician name, credentials]

Procedure

Full Procedure Title: [Radiofrequency ablation / Thermal neurotomy] of [medial branch nerves / dorsal rami / medial branch nerves and dorsal rami], [cervical / thoracic / lumbar] region; facet joints treated: [specific facet joint levels with laterality]; corresponding target nerves: [each corresponding medial branch nerve and/or dorsal ramus]; imaging guidance: [fluoroscopy / CT]. (State as a single complete title. Include both facet joints treated and the corresponding target nerves. Do not omit laterality or levels; if uncertain, insert a clarification-required placeholder.)

Pre-Procedure Diagnosis: [Facet-mediated axial pain description, e.g., lumbar spondylosis without myelopathy]

Post-Procedure Diagnosis: [Diagnosis] (Typically same as pre-procedure)

Operators: [Primary operator name, credentials]; [assistant(s) if present]; [sedation clinician if separate]

Indication and Medical Necessity

[Concise summary including: pain location and facet-mediated pain hypothesis; duration; severity with baseline pain score and scale used; functional limitations; conservative treatments attempted and failed (PT, medications, activity modification); pertinent imaging findings that rule out alternative pathology.] (Include only details explicitly known. Keep focused on elements establishing medical necessity.)

Prior Diagnostic Blocks

(Document qualifying diagnostic medial branch block(s). If this is a repeat RFA without new diagnostic blocks, skip to Repeat RFA section below.)

• Diagnostic Block #1:
  • Date: [Date]
  • Levels and Laterality: [Each facet joint level and side]
  • Injectate: [Drug name, concentration, volume per site]
  • Pre-block Pain Score: [Score and scale]
  • Post-block Pain Score: [Score and scale at defined timepoint]
  • Percent Pain Relief: [% relief]
  • Duration of Relief: [Duration] [consistent / inconsistent] with anesthetic used
  • Functional Improvement: [Functional gains observed]
• Diagnostic Block #2 (Confirmatory): (Include if performed)
  • Date: [Date]
  • Levels and Laterality: [Each facet joint level and side]
  • Injectate: [Drug name, concentration, volume per site]
  • Pre-block Pain Score: [Score and scale]
  • Post-block Pain Score: [Score and scale at defined timepoint]
  • Percent Pain Relief: [% relief]
  • Duration of Relief: [Duration] [consistent / inconsistent] with anesthetic used
  • Functional Improvement: [Functional gains observed]

Target Concordance: Today's ablation targets correspond to the diagnostic block targets. (This statement is required.)

Repeat RFA: (Include instead of diagnostic block details if repeating RFA without new blocks) Prior RFA date: [date]; levels/laterality: [levels and sides]; degree and duration of benefit: [response description]; clinical rationale supporting recurrence of same pain generator: [rationale].

(If diagnostic block response data are required but unavailable, insert placeholder prompting reconciliation before note finalization.)

Pre-Procedure Safety Screen

• Allergies: [None known / Contrast / Local anesthetics / Antiseptics / Latex / Other: specify]
• Anticoagulation: [None / Agent, last dose, held/continued per plan]
• Infection Screen: [No fever, no systemic or local infection / Findings: specify]
• Pregnancy Status: [N/A / Negative / Not tested—specify reason]
• Implanted Devices: [None / Device type, management plan (interrogated / turned off / no adjustment needed)]
• Baseline Neurologic Status: [Intact / Pre-existing deficits: specify for post-procedure comparison]

Informed Consent and Time-Out

Consent: Informed consent obtained after discussion of procedure purpose, alternatives (continued conservative care, repeat blocks, surgical evaluation if appropriate), and material risks including bleeding, infection, allergic reaction, post-procedure neuritis or pain flare, temporary or permanent nerve injury, new or worsened pain, weakness or numbness, [and region-specific risks such as pneumothorax for thoracic procedures].

Time-Out: Performed confirming correct patient identity, correct procedure, correct side/laterality and vertebral levels, allergies reviewed, anticoagulation and implant status reviewed, imaging available, and equipment ready.

Anesthesia and Sedation

Anesthesia Type: [Local anesthetic only / Minimal sedation / Moderate sedation / MAC]

Sedation Medical Necessity: [Patient-specific justification for sedation] (Required if moderate sedation or MAC was used. Anxiety or preference alone generally insufficient; document clinical reason such as inability to remain motionless, movement disorder, or prior failed unsedated attempt.)

Medications: Local anesthetic for skin infiltration: [drug, concentration, total volume]. [Sedatives if used: drug, dose, route for each]. [Adjuncts: antiemetic, anxiolytic, antibiotic prophylaxis if used].

Monitoring: [Pulse oximetry, blood pressure, ECG, capnography if applicable] monitored by [name/role].

Procedure Details

Positioning and Preparation: Patient positioned [prone / lateral]. Skin prepared with [preparation solution]. Sterile draping applied.

Imaging Guidance: [Fluoroscopy / CT]. Views used: [AP / oblique / lateral]. Fluoroscopy time: [time with units] (if tracked).

Targets Treated: (List each target. Do not omit laterality or levels.)

• [Facet joint level], [right / left]: [Corresponding medial branch nerve(s) and/or dorsal ramus]
• (Add additional targets as needed)

Equipment: RF cannula: [gauge], active tip [length]. Technique: [conventional thermal / cooled / bipolar]. Grounding pad: [location].

Placement Verification: Final cannula position confirmed with [multi-view imaging / views used]. [Contrast used: type, volume, appropriate spread pattern confirmed, no intravascular uptake / No contrast used].

Sensory and Motor Stimulation: [Performed / Not performed] (If not performed, state explicitly rather than omitting.)

• Sensory Testing: [Frequency, e.g., 50 Hz]; threshold [voltage]; concordant pain reproduction: [yes / no]
• Motor Testing: [Frequency, e.g., 2 Hz]; maximum voltage tested: [voltage]; [paraspinal response used as proximity marker if applicable]; no distal limb contraction or radicular symptoms: [confirmed / findings]

Pre-Lesion Local Anesthetic: [Drug, concentration, volume] injected through cannula at each site prior to lesioning.

Lesioning Parameters: (Document for each target. Insert placeholder if RF generator data unavailable.)

• [Target: facet joint level, laterality – target nerve(s)]
  • Temperature: [°C]
  • Duration per lesion: [seconds]
  • Number of lesions: [number]
  • Impedance: [ohms] (if recorded)
  • Notes: [Aborted lesions and reason, if any]
• (Add additional targets as needed)

Post-Lesion Injection: [Not performed / Performed: drug, concentration, volume per site] (Include only if local anesthetic and/or corticosteroid injected after lesioning to reduce post-procedure neuritis.)

Procedure Completion: Cannulas removed intact. Hemostasis achieved. Dressing applied. Patient [tolerated procedure well / tolerance description].

Immediate Post-Procedure Assessment

Patient Status: Procedure tolerated: [yes / no]. Immediate post-procedure pain score: [score and scale].

Neurologic Examination: [Focused motor and sensory exam findings appropriate to region treated; gait assessment if applicable].

Complications: [None / Complication: type (vasovagal episode / bleeding/hematoma / new neurologic deficit / allergic reaction / pneumothorax concern / equipment malfunction / other), timing, management, and patient response]. (Always include explicit statement even if none.)

Plan

Expected Course: Post-procedure soreness expected for several days. Delayed-onset neuritis-type discomfort possible. Therapeutic benefit typically assessed over days to weeks.

Activity: [No driving for 24 hours due to sedation / Activity as tolerated]. [Additional restrictions if any].

Medications: [Recommended analgesics for soreness (acetaminophen, NSAIDs if not contraindicated); prescriptions provided if any].

Return Precautions: Patient instructed to seek care for fever/chills, progressive redness or drainage at site, severe or progressive weakness/numbness, new bowel/bladder dysfunction, or severe headache.

Follow-Up: [Timing, typically 2–6 weeks] to assess pain score, functional status, medication use, [and PT participation if applicable].

Attestation

Procedure performed by: [Operator name, credentials]

Signature/Date/Time: [Signature and timestamp]

Imaging Documentation: [Fluoroscopic / CT] images stored in PACS per facility protocol. Fluoroscopy time: [time recorded].