Sample Opnote – Sitting Cervical Interlaminar Epidural Steroid Injection

[This is a sample procedure note and may not match the corresponding guide exactly: As with all procedures there will be slight variations based on body habitus, technique preference, laterality, etc. Treat this as a starting point for a template. The brackets {{ }} are used in the body as placeholders for dynamic variables.]

[Written for C7-T1 injection. Full procedure technique and overview here.]




Procedure: Cervical Interlaminar Epidural

Levels Treated: C7-T1

Laterality: NA

Pre-op diagnosis:

M48.02 – Spinal stenosis, cervical region

Post-op diagnosis: Same

Anesthesia: MAC

Pre-Procedure Review: The initial consultation report has been reviewed and there are no changes with regard to the patient’s medical, social history and review of systems. The patient states that the symptoms are stable and unchanged since the last visit. My findings on physical examination today are grossly consistent with those documented on the previous follow-up note, at which time today’s procedure was scheduled. I will proceed today with the scheduled procedure and see the patient back for follow-up. The patient states understanding of the plan, and is in agreement.

Indication: Treatment of pain of the neck (with or without radicular symptoms) secondary to cervical neuraxial inflammation secondary to pathology noted above.

Description:The history and physical examination were thoroughly reviewed to ensure accuracy, and the details of the cervical epidural steroid injection were discussed with the patient. The patient understands the risks and benefits involved. The patient has also been made aware of all alternative therapeutic options, and an informed consent was thereafter obtained. A time-out with two active identifiers of the patient, the procedure, and the site was performed. The patient then assumed a seated position on a chair. The back of the neck was widely sterilized with a Betadine solution and draped in a sterile fashion.

A “non-sting” local anesthetic was used to anesthetize the skin and tissues overlying the C7-T1 interspace. A Tuohy needle was advanced with fluoroscopic guidance and the epidural space was identified with the loss-of-resistance technique using saline. Correct placement of the needle tip was confirmed with multiple fluoroscopic views. Aspiration was negative for blood, CSF, or other fluid. Thereafter, 0.5 mL of contrast was slowly injected (without incident), confirming proper epidural spread. The steroid solution (dexamethasone 10mg in 5mL of preservative-free normal saline) was slowly injected. There were no paresthesias, and the needle was removed intact. There was no inordinate bleeding, and the patient tolerated the procedure well. The cervical area was cleaned and a sterile bandage was applied. Total fluoroscopy time was {{}}minutes ({{}}mGy).

The patient was then transferred to an observation room and recovered without incident. During this time, vital signs were taken every five minutes, and the patient’s level of consciousness and level of comfort were continually monitored. No adverse events were noted, and the patient was discharged home in stable condition. All potential side effects and adverse events have been discussed with the patient. The patient has been instructed to call my clinic at the first sign of an adverse event, or with any other concerning symptoms. A follow-up appointment has been made.

Anesthesia Addendum: {{standard anesthesia addendum if applicable}}