Medical Specialty:
Pain Management

Sample Name: Lumbar Epidural Steroid Injection - 3

Description: Lumbar epidural steroid injection for lumbar radiculopathy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Lumbar radiculopathy, 724.4.

POSTOPERATIVE DIAGNOSIS: Lumbar radiculopathy, 724.4.

PROCEDURE: Lumbar epidural steroid injection.

ANESTHESIOLOGIST: Monitored anesthesia care

INJECTATE USED: 10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.



DETAILS OF THE PROCEDURE: The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained. A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death. There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.

The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury. Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.

The L4-L5 interspace was identified fluoroscopically. A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.

A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5. Needle tip position was confirmed in the anterior posterior fluoroscopic view. The epidural space was located with the loss of pulsation technique. Aspiration of the syringe was negative for blood or cerebrospinal fluid. One millimeter of 0.9% preservative was injected with good loss resistance noted.

DISCHARGE SUMMARY: Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.

Keywords: pain management,