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Cervical Epidural Steroid Injection and Trigger Point Injection Transcription Sample

DESCRIPTION OF PROCEDURE:  The patient was brought in to the operating room and laid in the prone position. The patient's neck and shoulders were prepped and draped in the usual sterile fashion. The skin and underlying subcutaneous tissues overlying the C7-T1 interspace were identified and infiltrated with 5 mL of 1% plain lidocaine. A 17 gauge Tuohy needle was advanced through the anesthetized area into the cervical epidural space under direct visualization with fluoroscopy. Loss of resistance was confirmed with air and saline. An epidural catheter was passed up to the level of C5 on the right side. Three mL of Isovue dye was injected, which confirmed spread of the medication in the cervical epidural space from the level of C2 caudad to the level of T1. This was right greater than left sided spread of the medication. At this juncture, 5 mL of preservative-free 0.9% normal saline with 125 mg of Kenalog was administered. The needle was removed and a bandage was placed over the injection site. Two trigger points were then identified, one on cervical paravertebral area, on the right side, and the other along the trapezius muscle in the right shoulder. This area was prepped and 5 mL of 0.5% Marcaine with 10 mg of Depo-Medrol was deposited at each site in a fanning distribution. The needle was removed and bandages were placed over the injection sites. The patient was returned to the recovery room in stable condition.

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