Transforaminal Epidural Steroid Injection Sample Report

DATE OF PROCEDURE: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

PREOPERATIVE DIAGNOSIS:
Lumbar radiculopathy secondary to herniated disk at L5-S1.

POSTOPERATIVE DIAGNOSIS:
Lumbar radiculopathy secondary to herniated disk at L5-S1.

PROCEDURES PERFORMED:
1. Transforaminal epidural steroid injection, right L5.
2. Trigger point injection of the right lumbosacral area.

INDICATIONS FOR PROCEDURE: This (XX)-year-old Hispanic female presents with a six-month history of low back pain radiating to the right lower extremity and also has numbness of the toes. She received an epidural steroid injection recently, and she is about 50% improved and she is able to ambulate better. Her pain in the extremity has evidently decreased, and she is here for the second epidural steroid injection.

DESCRIPTION OF PROCEDURE: The patient was brought to the fluoroscopy imaging suite and was placed prone on the imaging table. The lumbosacral area was prepped with Betadine and was draped in the usual fashion. She was sedated using Versed and fentanyl and was monitored using noninvasive blood pressure and pulse oximetry throughout the procedure.

Once the patient was adequately sedated, the back was prepped with Betadine and was draped in sterile fashion. Using C-arm fluoroscopy, the lumbar vertebral bodies were identified, and the upper endplate of L5 vertebra was aligned with 20 degrees of lateral tilt. The right L5 pedicle was in view. At this time, the skin was anesthetized using 1% lidocaine, and a 22-gauge spinal needle was then advanced toward the 6 o’clock position on the right L5 pedicle under fluoroscopic guidance.

Once the needle tip was in position, the position was checked in lateral view, and the needle tip was found to be in the upper third of the foramen. After negative aspiration for any blood or CSF, 1 mL of Isovue-M 200 was injected, which showed the dye spreading along the nerve root and also in the epidural space. 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. She was monitored after the procedure in clinic for 1 hour and was discharged home in stable condition.

The patient was asked to follow up in the pain clinic in two to three weeks, if the patient has any significant improvement in her symptoms. If the patient did not receive any meaningful pain relief, we asked the patient to follow up directly with Dr. Jane Doe prior to the third epidural injection.

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