Sample Type / Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection - 1
L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.
(Medical Transcription Sample Report)
Herniated lumbar disk with intractable back pain.POSTOPERATIVE DIAGNOSIS:
Herniated lumbar disk with intractable back pain.OPERATION PERFORMED:
L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.ANESTHESIA:
The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin over sacral hiatus. A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood. A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level. After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected. The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected. Needle and catheter were removed intact. The patient was discharged in stable condition.
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