Dr Tim GriceHJH,M

DR TIM GRICEINFORMATION SHEET AND CONSENT FORCOMBINATION SACROILIAC, SUPERIOR CLUNEAL AND FACET JOINT RADIO FREQUENCY NEUROTOMY TREATMENT

RADIOFREQUENCY NEUROTOMY (RFN)

RFN is a procedure performed on the nerves that surround the painful Sacroiliac and Facet joints as well as the Superior Cluneal Nerves. These areas are often the cause of low back and they can also cause pain to the legs. The aim of RFN is to interrupt the nerve supply; decreasing the pain signals being sent to your brain.

This procedure does not treat the underlying cause of the pain. Also, this procedure does not give permanent relief from pain, as the nerves eventually recover and the pain can return. However, RFN may provide relief for greater than 9-12 months. If the initial treatment is successful, this procedure can be repeated multiple times. Usually prior to this treatment, you will need to have had a positive Medial Branch Block (MBB) of the Facet Joints and injection into the painful Sacroiliac Joint and Superior Cluneal Nerves areas to prove these are the causes of the pain before the RFN procedure is performed.

The procedure is performed in a similar way to a Medial Branch Block and other prior injections, but usually with sedation in theatre.However, this procedure –

Targets nerves close to the Sacroiliac joint, Superior Cluneal nerves and Medial Branches of the Facet Joints

Takes longer to perform, Is more technically challenging, and Requires multiple levels of intervention.

COMBINED SACROILIAC, SUPERIOR CLUNEAL AND FACET JOINT PAIN

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Dr Tim Grice Sacroiliac joint Pain Distribution Superior Cluneal Nerve Pain Distribution

Sacroiliac Joint Superior Cluneal Nerve

Facet Joints of the Spine Medial Branch Nerve to the Facet Joints

INDICATORS

Low Back pain Pain that radiates down the lateral thighs and occasionally the lateral calves Low back pain that spreads to the buttocks.

WHEN BOOKING THE PROCEDURE

On the day of booking your procedure, please advise staff if you are – Taking blood thinners (especially warfarin and clopidogrel) Diabetic Pregnant, or any chance of being pregnant

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Dr Tim Grice Allergic to:

o Shellfisho Steroids

o Local anaestheticso Iodine

o Betadineo Chlorhexidine

Unwell or have an infection

FACET JOINT RADIOFREQUENCY NEUROTOMY

DAY OF THE PROCEDURE

DO NOT eat or drink (for 6 hours before your procedure), TAKE your usual medications with a small amount of water (apart from those mentioned

previously), and ARRANGE for someone to accompany you home.

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Dr Tim GriceSACROILIAC JOINT RADIOFREQUENCY NEUROTOMY

DURING THE PROCEDURE

After arriving you will need to complete the necessary paperwork. Then – You will change into a hospital gown, A small drip will be inserted into one of your veins, You may be offered mild/moderate sedation Your heart rate and blood pressure will be monitored throughout the procedure, You will lie face down on an x-ray table, then the skin over the area to be injectedwill be

cleaned with an antiseptic solution, A sterile barrier will be created, A local anaesthetic will be injected to numb the area, An x-ray machine will be used to guide a small needle towards the nerve, You may experience some discomfort, however this usually subsides and can be treated

with icepacks and medication.

Superior Cluneal Nerve

AFTER THE PROCEDURE

You will be monitored in a recovery area until you are ready to go home. This usually takes between 60 – 120 minutes.

Preferably, someone will take you home and stay with you for the next 24 hours. Pain may return when the anaesthetic wears off. Some people experience an initial

increase in pain and stiffness, which may continue for several days. If necessary you may apply an ice pack to the area for 20 minutes at a time, for 1-2 days following the procedure.

You may take simple painkillers such as Paracetamol and often opioids to ease any discomfort.

Remove any dressing the day after your procedure.4

Dr Tim Grice Avoid a rapid increase in your activities. Gradually increase your daily activities as

tolerated. Discuss this with your doctor. If you have received sedation during your procedure, the effects may last up to 24 hours.

Due to the effects, you may not remember some of the information given to you during the procedure. For the next 24 hours, you SHOULD NOT –

o Drive a vehicle, o Drink alcohol, o Operate machinery,

o Make important decisions, o Sign legal documents, or o Travel unaccompanied.

COMPLICATIONS

This procedure is usually safe and uneventful. However, as with any procedure there is always a small degree of risk.

Common Complications Continuing pain / no benefit

Minor bleeding in the area injected Bruising in the area injected Temporary weakness or numbness from the local anaesthetic Brief increased pain that may fluctuate in intensity

More Serious Side Effects Damage to surrounding structures

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Dr Tim Grice Infection Permanent nerve injury Allergy to the anaesthetic drugs used as part of the procedure Increase of any pre-existing medical condition such as cardiac conditions Bruising around the area from needle trauma Aspiration during sedation Eye injury while lying prone (face down) Serious anaesthetic / procedural complications and very rarely death Increased lifetime risk of cancer due to X-rays exposure Very rare risk of surgery due too injuries from the procedure

Please discuss with your doctor any other questions you may have about this procedure or this information sheet. If you agree to have the procedure, you will be asked to sign a consent form.If you notice –

Any swelling from the site, Any bleeding from the site, or Have any other concerns,

Please contact your General Practitioner, Queensland Pain Clinic, or the Emergency Department of your local hospital.

Dr Tim Grice

Specialist Pain Medicine Physician

Queensland Pain Doctor

Suite 4, Level 4.

123 Nerang St Southport, QLD 4215

Phone: 07 5532 0468 F

ax: 07 5528 3850

Email: admin@qpdr.com.au

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Dr Tim Grice

CONSENTI have had time to read and I understand the information and instructions provided to me regarding the Radiofrequency Neurotomies to Sacroiliac Joint, Superior Cluneal Nerves and Facet Joint procedures and post-procedural care.

Common Complications:- Continuing pain / no benefit, Minor bleeding in the area injected, Bruising in the area injected, Temporary weakness or numbness from the local anaesthetic, Brief increased pain that may fluctuate in intensityMore Serious Complications:- Damage to surrounding structures, Infection , Permanent nerve injury, Allergy to the anaesthetic drugs used as part of the procedure, Increase of any pre-existing medical condition such as cardiac conditions, Bruising around the area from needle trauma, Aspiration during sedation, Eye injury while lying prone (face down), Serious anaesthetic / procedural complications and very rarely death, Increased lifetime risk of cancer due to X-rays exposure, Very rare risk of surgery due too injuries from the procedure

I understand that I have the right at any stage to change my mind even after I have signed this document.

I have had time to ask any questions and raise any concerns I have regarding this procedure and its risks with Dr Tim Grice.

I understand that there are alternatives to this procedure including; no –treatment, medication and psychological support.

I understand that if there were any immediate life threatening Incidents happen during the procedure that they will be treated as part of the procedure.

I understand and agree that a sample of my blood can be taken and tested should a member of staff have exposure to my bodily fluids as part of the procedure.

I believe that all my questions have been discussed and answered to my satisfactionI

I understand that this is not a permanent treatment and the pain may return but repeat procedures may be a treatment option in the future.

I consent to this procedure with / without sedation (delete one option)

Patient Name: ___________________________________ Date: _________

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Dr Tim GricePatient Signature: ________________________________

Doctor Name: ___________________________________

Doctor Signature: ________________________________

CONTACT DETAILS

Dr Tim Grice Specialist Pain Medicine Physician Queensland Pain DoctorSuite 4, Level 4, 123 Nerang St, Southport, QLD 4215Phone: 07 5532 0468 Fax: 07 5528 3850 Email: admin@qpdr.com.au

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