Sample Name: Cervical Epidural Steroid Injection
Description: Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.
(Medical Transcription Sample Report)
PROCEDURE: Cervical epidural steroid injection without fluoroscopy.
ANESTHESIA: Local sedation.
VITAL SIGNS: See nurse's notes.
DETAILS OF PROCEDURE: INT was placed. The patient was in the sitting position. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between C7-T1 ________. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted. After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected. Neosporin and band-aid were applied over the site. The patient discharged to recovery room in stable condition.
Keywords: pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, injection,