# Ultrasound Guided Perineural injection



## alysonrs (Apr 21, 2015)

I have this note to code and not sure what CPTs should be billed.  Anyone have any suggestions?  Any help would be greatly appreciated!  

Pre-op. Diagnosis: 
 	?  Peripheral Neuropathy 356.9 
 	?  Pain, Lower Extremities 729.5 

   Post-op. Diagnosis: 
 	?  Same as pre-op diagnosis 

   Operation: 
 	?  Ultrasound guided perineural injection of the left deep peroneal nerve 
 	?  Saphenous nerve block left 
 	?  Sural nerve block left 
 	?  Electronic stimulation of the lower extremities 

   Anesthesia: 
 	1.0% Lidocaine

   Indications: 
 	68 year old with EMG/NCV demonstrated peripheral neuropathy and supportive laboratory studies presents today for the sixth in a series of 6 injections with electrostimulation in an effort to control the pain. She underwent Combined Electro chemical Therapy in April of 2014 with good results until recently. 

The patient complains of numbness as well as positive symptoms of burning, tingling, pins and needles, cramping, and icy cold sensations.

   Details of Procedure: 
 	PROTOCOL: Gray scale, Color and Duplex Doppler ultrasound for needle guidance and procedure monitoring. 

COMPARISONS: None.

Left Deep Peroneal Nerve:

Ultrasound guidance was provided through the entire injection procedure from needle guidance for anesthesia, and injection of anesthetic agent.

Initial images of the anterior ankle at the level of the malleoli were acquired to identify bone and soft tissue landmarks for needle access, insertion, and positioning of the needle tip in close proximity to the deep peroneal nerve. The entire process of needle positioning, injections of all agents were monitored and supervised through the entire procedure. Ultrasound guidance was used to template the skin for needle approaches. The skin was marked, sterilized using Betadine. Local anesthesia was administered with 1 cc of 1.% lidocaine plain through a 25-gauge needle.

After local anesthesia took effect, under direct ultrasound visualization, a 1.75 inch 22-gauge needle was directed from a lagteral approach to the lateral aspect of the deep peroneal nerve next to the dorsalis pedis artery. After positioning the needle tip, and negative aspiration, 1 cc bicarbonated 0.5% bupivacaine was administered. Flow of injectate was observed around the perineuron. The tip of the needle was visualized and located at all times to ensure accurate needle positioning and to avoid unintentional lysis or dissection of vital structures. Color Doppler ultrasound evaluation also insured avoidance of vascular structures.

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Attention was then turned to blocking the superficial nerves laterally at the sural, and medially at the saphenous nerves. After sterile prep using a 1.5 inch 25 gauge needle a subcutaneous infiltration with 1 cc of 0.5 % bupivacaine was delivered subcutaneously in the area of each nerve without complication.

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The patient was then placed in the seated position in a recliner. Up to eight 5"x8" electrode pads, were placed on the treatment sites per protocol. Electroanalgesia (EA) was accomplished by placing the electrodes over the treatment area for up to 25 minutes. The strength of EA treatment was reduced to the ability of the affected nerves to transmit pain signals and, promote healing by means of the depolarization on the nerve cells.

The Neuromed electroanalgesia syatem was used to deliver specific pre-programmed software algorithms to bioelectrically trigger different desired physiological mechanisms of actions from frequencies starting at .1 Hz - .5 Hz (for stimulation) then changed throughout the treatment to include a 5,000 Hz frequency for 15 minute treatment. Electroanalgesia frequencies ranged in the low (<2,000 Hz) and medium frequencies(2,000 - 100,000 Hz) . Carrier frequency and intensity(dosage) was matched to the appropriate level at the time of treatment. 

   Specimens: 

   Complications: 
 	None. Successful and uncomplicated ultrasound guided injection deep peroneal perineural injection, superficial nerve blocks, and electronic stimulation

   Findings: 

   Notes: 
 	Pre BP112/62 HR 80
Post BP 112/64HR80

At the end of the procedure vital signs are noted be stable. Precautions were given complications and the patient advised to call if these should occur. The patient will follow-up as scheduled in the office.


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## dwaldman (Apr 21, 2015)

64450 x3 LT
76942


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