Lumbar Epidural Steroid Injection Procedure Description Sample #1
PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.
POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
COMPLICATIONS: Nil.
SPECIMENS REMOVED: Nil.
DETAILS OF PROCEDURE: The patient was evaluated in the preoperative holding area. The history and physical were reviewed again. The consent was checked. Details of the procedure, risks, benefits, and complications were discussed with the patient. The patient agreed for the procedure and was taken to the procedure room and laid prone on the procedure table.
The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-5 interlaminar space was identified using fluoroscopy. The skin was anesthetized with 1% lidocaine and 17 gauge 3.5 inch Tuohy needle was gently introduced into interlaminar space using intermittent fluoroscopy and loss of resistance technique.
After identification of the epidural space, the confirmation was obtained by using 1.5 to 2 mL of Isovue dye. After confirmation of the correct placement of the needle in the epidural space, an 8 mL solution containing 0.25% Marcaine and 120 mg Depo-Medrol was slowly injected into the epidural space.
The patient tolerated the procedure well. There were no immediate complications and was taken to the postop area and was monitored as per protocol. The patient was discharged home on the same day with advice to attend the Pain Clinic as arranged earlier.
Lumbar Epidural Steroid Injection Procedure Description Sample #2
PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.
POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
DETAILS OF PROCEDURE: The patient was evaluated in the preoperative area. The history and physical details of the procedure including risks, benefits and complications were discussed with the patient. The patient agreed for the procedure.
He was taken to the procedure room. The patient was laid prone on the procedure table, and his skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 space was identified using the fluoroscopic guidance. The skin was anesthetized with 1% lidocaine including the subcutaneous tissue.
The L4-L5 space was identified using the intermittent fluoroscopic and loss of resistance technique. After identification of the L4-L5 epidural space, which was confirmed by using 1.5% Isovue, an 8 mL solution containing 0.125% lidocaine and 120 mg of Depo-Medrol was gently introduced into the epidural space.
The patient tolerated the procedure well. There were no immediate complications. The patient was taken to the postoperative area and was monitored as per the protocol. The patient was discharged home on the same day with advice to attend the pain clinic as arranged earlier.
Lumbar Epidural Steroid Injection Procedure Description Sample #3
PROCEDURES PERFORMED: Lumbar epidural steroid injection, fluoroscopy, epidurography and IV sedation.
DETAILS OF PROCEDURE: A solution of Ringer’s lactate was commenced in the patient’s right hand. She was given a total of 4 mg of Versed intravenously and monitored with blood pressure and pulse oximetry.
The patient was placed prone on the x-ray table with pillows under her pelvis. Her lumbar area was painted with alcohol and Betadine. Sterile drape was applied to her lumbar area. Fluoroscopy was used to identify the L5-S1 disk space.
Then, 1.5% lidocaine with epinephrine was used to anesthetize the skin and visualized the L5-S1 interspace. Under fluoroscopic guidance, a 17 gauge Tuohy needle was advanced into the epidural space to the left of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage. Two milliliters of Isovue 300 was injected through the needle. This revealed flow of contrast in the epidural space to the left of the midline. This was confirmed under lateral fluoroscopy.
We then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken. The patient was returned to the recovery room where she was observed and monitored for approximately 1 hour before being discharged.
X-RAY REPORT: On the lateral view of the lumbar spine, contrast can be seen extending from L3 as far as the sacrum. On PA view, contrast can be seen extending from the L3 as far as the sacrum with bilateral infiltration of contrast slightly moved to the left than the right.
Lumbar Epidural Steroid Injection Procedure Description Sample #4
PROCEDURES PERFORMED: Lumbar epidural steroid injection, fluoroscopy, epidurography.
DETAILS OF PROCEDURE: The patient was placed prone on the x-ray table with pillows under her pelvis. The lumbar area was cleansed with alcohol and Betadine. Sterile drape was applied to his lumbar area. Fluoroscopy was used to identify the L5-S1 interspace. Lidocaine 1% with epinephrine was used to anesthetize the skin and attention was taken at the L5-S1 interspace.
Under fluoroscopic guidance, a 17 gauge Tuohy needle was advanced into her epidural space to the right of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage.
About 2 mL of Isovue M 300 was injected through the needle. This revealed good flow of contrast in the epidural space to the right of the midline. This was confirmed with lateral fluoroscopy. We then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken.
The patient was returned to the recovery room and she was observed and monitored for approximately 30 minutes before being discharged.
X-RAY REPORT: On the lateral view of the lumbar spine, contrast can be seen extending from L3-4 disk space as far as the sacrum. On PA view, it was somewhat difficult to make out the contrast, but we could see bilateral distribution of contrast extending from proximity of L4-5 as far as the sacrum.
