SAMPLE REPORT - LUMBAR EPIDURAL STEROID INJECTION - LESI

Note: In major hospitals, the pain clinic physicians are usually anesthethesiologists - this is what they do when they aren't putting you to sleep! :)

PREPROCEDURE DIAGNOSIS: Lumbar radiculopathy.

POSTPROCEDURE DIAGNOSIS: Lumbar radiculopathy.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

ANESTHESIOLGIST: George Washington, M.D.

REFERRING PHYSICIAN: Abraham Lincoln, M.D.

ANESTHESIA GIVEN: Local.

INDICATIONS FOR PROCEDURE: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections.

DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus position. The L4-5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo Medrol 80 mg, normal saline 10 cc and lidocaine 1% at 5 cc was injected. No complications were encountered and the patient was returned to the outpatient surgery department in stable condition.

PLAN: To repeat this procedure in two weeks.

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