Review these instructions at least twice

(Failure to follow these guidelines may result in cancellation of your SCS Trial)
Performance Spine & Sports Specialists, PA
Spinal Cord Stimulator Trial Guidelines
Patient Name: ________________________________________________________________________________
Date and Time: _______________________________________________________________________________
Location: Performance Spine & Sports Specialists 520 Maple Avenue Suite A Reidsville, NC 27320
Any other allergies: ____________________________________________________________________________
ARRIVAL TIME: No later than ½ hour before your procedure. You will have an IV started for IV sedation and
for your antibiotic. If you are allergic to Penicillin, you will be given IV Cleocin. Please pick up your antibiotic
prescription at your pharmacy at least 48 hours before your procedure and bring your bottle of Keflex or
Cleocin with you to the office on the day of your procedure
1. Do not eat or drink for 8 hours prior to your procedure. This includes chewing gum and hard candy. We ask
that you drink plenty of fluids several days before the procedure.
2. You MUST have a driver accompany you. You will NOT be able to drive home!!
3. It is recommended that you take your Valium (Diazepam) and your normal pain medications as directed 4. You will be given a prescription for labwork. Please have this completed no later than two days prior to
your procedure. We will need those results faxed to our office stat. Fax # is 336-349-5056. 5. Allow 2 hours for the SCS trial. You will remain in our recovery area for 30-45 minutes.
6. Do NOT take any blood thinners such as aspirin or Coumadin for 6 days prior to your procedure, unless you
check with the office first. Lovenox is okay. Continue to take your other medications such as blood
pressures or diabetes medications.

7. You MAY take Tylenol, Celebrex, Mobic and other traditional anti-inflammatory medications.
8. If you are ill, running a fever, coughing, have diarrhea, or have any other current infection you MUST call the office. We will have to reschedule your SCS trial. 9. You may experience some pain at the injection site after your procedure. Applying ice for 20 minutes 3 times a day may be beneficial. You may resume your prescribed pain medications. 10. If you have any questions, or there is ANY CHANGE IN YOUR MEDICAL STATUS, please call our
11. Please call at least 24 hours in advance if you must cancel your procedure. Also, please plan according
to the above guidelines as failure to do so may result in cancellation of your procedure.
12. ADDITIONAL INSTRUCTIONS: ___________________________________________________________ PATIENT SIGNATURE ____________________________________ DATE _____________________________ 520 Maple Avenue Suite A Reidsville, NC 27320 336-349-5050 Fax 336-349-5056


Draft – zest quest outcomes/grade level indicators

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