Sample Name: Lumbar Epidural Steroid Injection - 1
Description: Lumbar epidural steroid injection, intralaminar approach, seated position. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.
(Medical Transcription Sample Report)
OPERATION: Lumbar epidural steroid injection, intralaminar approach, seated position.
ANESTHESIA: Local and sedation.
DESCRIPTION OF PROCEDURE: The procedure risks, hazards and alternatives were discussed with the patient and a proper consent was obtained. The patient was placed in a lateral decubitus position and monitored with an EKG, blood pressure cuff and pulse oximetry. The skin was prepped and draped in the sterile classic fashion. Excess cleansing solution was removed from the skin. Local anesthesia infiltrated subcutaneous and deep at *. An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe. Once the epidural space was identified, a negative aspiration of the heme or CSF was done. This was followed by an injection of 120 mg methylprednisolone acetate and normal saline in aliquots of 2, 3 and 3 cc. Negative aspirations were done prior to each injection. The needle was cleared with saline prior to its withdrawal. The patient tolerated the procedure well without any apparent difficulties or complications.
Keywords: pain management, loss of resistance technique, methylprednisolone acetate, lumbar epidural steroid injection, epidural steroid injection, tuohy needle, steroid injection, epidural space, intralaminar approach, injection, intralaminar, saline, epidural,