Sample Type / Medical Specialty: Pain Management
Sample Name: Depo-Medrol Injection
Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance. The patient is a 51-year-old female with back pain referring into the right leg.
(Medical Transcription Sample Report)
Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.INDICATION:
The patient is a 51-year-old female with back pain referring into the right leg.RISKS VERSUS BENEFITS:
The risks and benefits were discussed with the patient prior to the procedure. She agrees to accept the risks and signs a written consent to proceed with the procedure.DESCRIPTION OF PROCEDURE:
The patient was placed prone on the table. The skin was thoroughly cleansed with Betadine swabs x3 and wiped off with a sterile gauze. The subcutaneous intramuscular and interligamentous region was anesthetized with 4% lidocaine.
A 3-1/2-inch 20-gauge Tuohy catheter was directed under intermittent fluoroscopic guidance at the lamina. Once the lamina was detected, the catheter was directed cephalad and medially and loss of resistance technique was used to determine the epidural space.EPIDUROGRAM:
Omnipaque 300 1.5 mL was placed just to the right of the midline. This was viewed on the AP and lateral projections. It showed typical epidural spread pattern with good cephalad and caudad flow, and the flow was unrestricted.
Depo-Medrol 120 mg along with an additional bacteriostatic normal saline for a total of 60 mL injected solution was placed just to the right of the midline at L5-S1.
The patient tolerated the procedure well without procedural complications. She will follow up with me in the office in the next few weeks to monitor her response to the injection.
pain management, epidural steroid injection, fluoroscopic guidance, depo medrol, injection,
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