Medical Specialty:
Pain Management

Sample Name: Epidural Steroid Injection - 2

Description: Caudal epidural steroid injection without fluoroscopy.
(Medical Transcription Sample Report)

PROCEDURE: Caudal epidural steroid injection without fluoroscopy.

ANESTHESIA: Local sedation.

VITAL SIGNS: See nurse's records.

PROCEDURE DETAILS: INT was placed. The patient was in the prone position. The back was prepped with Betadine. Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus. A 18-gauge Tuohy needle was then placed into the epidural space. There were no complications from this (no blood or CSF). After negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to outpatient recovery in stable condition.

Keywords: pain management, epidural space, epidural steroid injection, caudal epidural, caudal, fluoroscopy, steroid, epidural, injection,