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Pain Clinic Lumbar Epidural Steroid Injection Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Multiple thoracolumbar vertebral compression fractures.

POSTOPERATIVE DIAGNOSIS:  Multiple thoracolumbar vertebral compression fractures.

PROCEDURE PERFORMED:  Lumbar epidural steroid injection with fluoroscopy and epidurogram.

ANESTHESIA:  Local anesthesia with sedation.

INDICATION FOR PROCEDURE:  The patient is a (XX)-year-old Caucasian female seen in consultation regarding chronic low back pain and lumbar radiculopathy. The patient is on chronic steroids for chronic arthritis and does have multiple vertebral compression fractures, though she denies any recent trauma. The patient presents today for a lumbar epidural steroid injection with fluoroscopy and sedation. She describes her pain as 8/10 across the mid back and low back with shooting pains down the legs to the heels.

DESCRIPTION OF PROCEDURE:  The patient was identified in the holding area where the procedure of lumbar epidural steroid injection was confirmed. All questions were answered and informed consent obtained.  The patient was brought to the procedure suite and was given sedation with 50 of fentanyl and 1 mg of IV Versed. The patient was placed prone onto the operating room table where all monitors, including blood pressure, oxygen, EKG were connected and supplemental oxygen via nasal cannula at 3 liters per minute was given to the patient. Next, the back was cleansed with ChloraPrep and prepped in the normal sterile fashion with sterile towels. Following this, an AP view of the thoracolumbar spine was identified, including the multiple vertebral compression fractures. Under fluoroscopic guidance, 5 mL of 1% lidocaine was injected subcutaneously into the skin at the L3-L4 right interspace. The needle was slowly advanced under fluoroscopic guidance and lateral view, and using a glass syringe in loss of resistance technique, the epidural space was identified. Next, 3 mL of 300 M Isovue was injected under the lateral view and then confirmed via epidurogram on the AP view. After negative aspiration, a total of 5 mL of 0.25% Marcaine and 80 mg of Depo-Medrol was injected slowly with spread up to approximately T9 and spread down to L5. Next, the needle was removed. The back was cleansed and Band-Aid was placed over the puncture site. The patient was then turned supine onto the hospital gurney and brought to the recovery room where she was observed. There were no complications and she tolerated the procedure well.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:   Degenerative disk disease and multiple spinal stenosis and lumbar radiculopathy.

POSTOPERATIVE DIAGNOSES:  Degenerative disk disease and multiple spinal stenosis and lumbar radiculopathy.

PROCEDURE PERFORMED:  Lumbar epidural steroid injection #2 under fluoroscopy.

ANESTHESIA:  Local.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old Hispanic male who received an epidural steroid injection by Dr. John Doe on MM/DD/YYYY for low back pain and lumbar radicular pain.  The patient had more than 40% improvement in his symptoms. He is here for the second epidural steroid injection. I reviewed the medical records and discussed the epidural steroid injection again with the patient. I examined the patient. There is no new finding from previous examination. The risks, benefits, and alternatives were discussed in detail. The patient clearly understands and agrees to proceed with the procedure.

DESCRIPTION OF PROCEDURE:  The patient was brought to the fluoroscopy imaging suite. He was placed prone on the imaging table. The lumbosacral area was prepped with Betadine and was draped sterilely. Using C-arm fluoroscopy in the AP projection view, lumbar vertebral bodies were identified and the interspace between L5-S1 was selected for the injection. After anesthetizing the skin with 1% lidocaine, a 17-gauge Tuohy needle was introduced into the epidural space using fluoroscopic guidance and also loss of resistance technique. Once the needle tip was in the epidural space, 2 mL of Isovue-M 200 was injected, which showed the dye spreading adequately in the epidural space. This was checked in the lateral view also. After negative aspiration for any blood or CSF, 120 mg of Depo-Medrol mixed with 2 mL of 0.5% Marcaine was injected. The patient tolerated the procedure well.  He was monitored for 1 hour and was discharged home in stable condition.