DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Thoracolumbar radiculitis.
POSTOPERATIVE DIAGNOSIS: Thoracolumbar radiculitis.
PROCEDURES PERFORMED:
1. Lumbar epidural steroid injection, left T12-L1 transforaminal space.
2. Lumbar epidural steroid injection, right T12-L1 transforaminal space.
3. Epidurography.
4. Intravenous sedation.
5. Fluoroscopy for needle placement and aspiration.
6. Constant monitoring including pulse, pulse oximetry, electrocardiogram, blood pressure, and verbal monitoring.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female suffering long-term with historic and physical exam findings consistent with the above-described diagnosis. She requests the above-described procedure to help facilitate her physical therapy and recovery from this pain syndrome. She understands that the risks include, but are not limited to, bleeding, infection, nerve damage, pain, possible blood clots, disability, death, worsened pain, no relief of pain, need for further procedures, need for hospitalization, spinal headache, need for bedrest. Multiple questions were asked and answered in detail. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: After consent was obtained, a detailed allergy history was carried out and found to be noncontributory. The patient was administered IV access, transported to the fluoroscopic suite, laid prone on the fluoroscopic table, monitoring devices applied, and IV sedation administered. The lumbar spine was sterilely prepped and draped in the normal fashion. After satisfactory anesthesia was demonstrated, the procedure was commenced.
A 22-gauge spinal needle was passed through the skin and deep tissue down to the level of the left-sided T12-L1 transforaminal space. Multiple fluoroscopic images were used to direct the needle. Aspiration was carried out to be certain the needle was not intradural or intravascular. Then, 1 mL contrast was infiltrated. Target localization was noted with appropriate spread of contrast. In a separate syringe, 3 mL of Depo-Medrol and 2 mL of 0.5% Marcaine was drawn up. Half of this mixture was infiltrated. Dye washout was noted. Mild reproduction of symptoms was noted, which resolved spontaneously.
Attention was then directed towards the right-sided T12-L1 transforaminal space. Multiple fluoroscopic images were used to direct a 22-gauge needle. Aspiration was negative. Contrast was infiltrated. Target localization was noted with appropriate spread of contrast. The remainder of the previously drawn up mixture was infiltrated. Dye washout was noted. Mild reproduction of symptoms was noted, which resolved spontaneously.
Following the procedure, there was no sign of anaphylactic or anaphylactoid reaction. The patient was given detailed postinjection instructions and encouraged to monitor symptoms and call with any questions or concerns.
