DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Low back pain with radiculopathy.
POSTOPERATIVE DIAGNOSIS: Low back pain with radiculopathy.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
SURGEON: John Doe, MD
COMPLICATIONS: Spinal tap.
SPECIMENS REMOVED: None.
DESCRIPTION OF PROCEDURE: The patient was evaluated in the preoperative area, and the details of the procedure, risks, benefits, and complications were discussed with the patient. An MRI scan was reviewed. History and physical and consent was completed. The patient agreed for the procedure and was taken to the procedure room.
The patient was laid prone on the procedure table, and the L5-S1 epidural space was identified. The skin was cleaned with Chloraprep x2 and draped in a sterile fashion. After identification of the L5-S1 interlaminar space, a 17 gauge 3.5 inch Tuohy needle was gently introduced into the epidural space using intermittent fluoroscopy and loss of resistance technique. On reaching the epidural space, there was a sudden gush of clear fluid. The needle was immediately withdrawn and pressure was applied. The patient did not feel any headache or change in vital signs.
After making sure that the patient was comfortable and was not complaining of any related complications, the L4-L5 epidural space was identified with intermittent fluoroscopy and loss of resistance technique and a 3.5 inch needle was gently introduced after anesthetizing the skin. The space was easily identified, and confirmation of the epidural space was done by putting 1.5 mL of Isovue dye. After confirmation of the epidural space, an 8 mL solution containing 120 mg of Depo-Medrol and 0.125% Marcaine was slowly injected into the space.
The patient tolerated the procedure well, and there were no immediate complications. The patient was taken to the postoperative area and was started on IV drip of 500 mL of normal saline and was monitored for about 1-2 hours. The patient was also given coffee to drink. The patient did not complain of any headache or any numbness in the lower extremities. The patient was discharged home on the same day with the instructions to call the acute pain service in case she has worsening symptoms or severe headache. The patient understood the instructions, and she would be followed up in the clinic as arranged earlier. We would reschedule her for another LESI in the future.
