Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Epidurogram

Description: Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Right lower extremity radiculopathy with history of post laminectomy pain.
2. Epidural fibrosis with nerve root entrapment.

POSTOPERATIVE DIAGNOSES:
1. Right lower extremity radiculopathy with history of post laminectomy pain.
2. Epidural fibrosis with nerve root entrapment.

OPERATION PERFORMED: Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.

ANESTHESIA: Local/IV sedation.

COMPLICATIONS: None.

SUMMARY: The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root. The left side was quite open; however, that was not the side of her problem. At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root. A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location. After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.

There was a defect flowing in the medial epidural space at both sides. There were no complications.

Keywords: surgery, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples