Medical Specialty:
Pain Management

Sample Name: Epidural Steroid Injection

Description: Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.
(Medical Transcription Sample Report)

PRE-OP DIAGNOSES: Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.

POST-OP DIAGNOSES: Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.

INTERVAL HISTORY: Plans, risks and options were reviewed with the patient in detail. The patient understands and agrees to proceed.

ANESTHESIA: General Anesthesia

PROCEDURE PERFORMED: Epidural steroid injection, epidurogram, fluroscopy.

PROCEDURE: After informed consent, the patient was taken to the procedure room and placed in the prone position. EKG, blood pressure and pulse oximetry were monitored and remained stable throughout the procedure. The area was prepped and draped in the usual sterile fashion. Local anesthetic was infiltrated at the appropriate level. Fluoroscopic guidance was used to place a #20-gauge Tuohy epidural needle gently into the epidural space at L4-L5 using a paramedian approach. No blood or CSF was obtained on aspiration.

RADIOLOGY: Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging. The Needle was injected with Depo-Medrol 80 mg with Bupivacaine 1/16th , 8 cc total vol. Patient tolerated procedure well and was transferred to recovery room. Patient was discharged home with escort. Discharge instructions were given.

POST-OP PLAN: I will see the patient back in my office in two weeks. Continue p.r.n. medications as needed.

Keywords: pain management, back pain, herniated disc, lumbosacral facet, epidural needle, lumbosacral facet arthropathy, epidural steroid injection, facet arthropathy, epidural space, injection, epidurogram, fluroscopy, herniated, lumbosacral, steroid, arthropathy, epidural,