Medical Specialty:
Pain Management

Sample Name: Caudal Epidural Steroid Injection

Description: Caudal epidural steroid injection
(Medical Transcription Sample Report)


1. Caudal epidural steroid injection with contrast.
2. Utilization of fluoroscopy for confirmation of needle placement.

PREPROCEDURE PREPARATION: After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was used. For further details of IV sedation and infusion, please refer to anesthesia notes. Fluoroscopy was used to identify the appropriate anatomy. The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.

PROCEDURE DETAILS: The sacral hiatus was identified by lateral fluoroscopy, and overlying skin was anesthetized with 1% lidocaine plain. A 22-gauge needle was used to penetrate the sacrococcygeal ligament. Correct needle placement was confirmed by both AP and lateral fluoroscopy. After negative aspiration, administration of 0.5 mL of the contrast revealed correct needle placement within the sacral canal, as confirmed once again by biplanar fluoroscopy. There was neither intravascular nor intradural uptake. An additional 4.5 mL of contrast was administered, revealing additional epidural flow. After negative aspiration, 17 mL of medication were slowly administered followed by needle removal. The medication consisted of 5 mL of 0.25% Marcaine plain, plus 12 mg of betamethasone diluted in 10 mL of preservative-free normal saline. The patient tolerated the procedure well.

POSTPROCEDURE EVALUATION: After a 30-minute recovery period, during which no complications were noted, the patient was discharged home.

Keywords: pain management, steroid injection, 1% lidocaine, ap and lateral, asa monitors, caudal epidural steroid injection, epidural, fluoroscopy, ligament, needle placement, sacral hiatus, sacrococcygeal, caudal epidural, epidural steroid, caudal, steroid, injection,