Sample Name: Cervical Epidural Steroid Injection - 2
Description: Cervical epidural steroid injection, C5-6. The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level.
(Medical Transcription Sample Report)
PROCEDURE PERFORMED: Cervical epidural steroid injection, C5-6.
DETAILS OF PROCEDURE: The patient was brought to the operating theater and placed prone onto the radiolucent table. Subsequent monitored anesthesia care was administered. The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level. The neck area was then prepped with Betadine solution and draped sterile. A metallic marker was placed over the C5-6 lamina and a skin wheal was raised in the skin. A #20-gauge Tuohy needle was then advanced into the spinal canal using 1% Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined. The needle was redirected into the interlaminar space and advanced to the previously determined level. A 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space. When a free flow of air was produced, a solution of 80 mg Depo-Medrol, 2 cc of 1% Xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space. The Tuohy needle was removed. Betadine was cleansed from the skin. A bandage was placed over the needle entrance point. The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia. The patient was taken to the recovery room in stable condition.
Keywords: pain management, c-arm, cervical epidural steroid injection, ap view, lumbar spine, tuohy needle, epidural steroid, steroid injection,