Sample Opnote – Transforaminal 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 as if left sided at L4-L5 and L5-S1 and done as a therapeutic injection with steroid. Full procedure technique and overview here.]




Procedure: Lumbar Transforaminal Epidural (Therapeutic)

Levels Treated: {{L4-L5,L5-S1}}

Laterality: {{Left}}

Pre-op diagnosis:

M48.061 – Spinal stenosis, lumbar region without neurogenic claudication

M51.26 – Other intervertebral disc displacement, lumbar region

Post-op diagnosis: Same

Anesthesia: Local

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: Axial back pain with radicular symptoms, or isolated radicular pain (without associated back pain) resistant to other therapeutic means or when surgery is not indicated.

Description: The history and physical examination were reviewed to ensure accuracy, and the details of the procedure were reviewed with the patient who understands all of the risks and benefits involved. All questions have been answered, and the patient is aware of all alternative therapeutic options. Informed consent was obtained, and the patient was directed to the procedure room. A “time-out” with two active identifiers of the patient, the procedure, and the site was performed. The patient was positioned prone on the fluoroscopy table. All pressure points were padded and checked routinely. The patient’s blood pressure, heart rate, pulse oximetry, and level of consciousness were monitored throughout. The back was widely sterilized using Betadine solution and was draped in a sterile manner.

Starting with the L4 vertebral level, lidocaine was used to make a skin wheel directly over a point inferior and lateral to the inferior-lateral portion of the {{left}} transverse process. The subcutaneous tissue was then anesthetized, and a Quincke needle with a 30-degree bend at the tip was advanced in a target fashion using fluoroscopic guidance in the AP view. The needle was advanced until the tip made contact with the most infero-medial portion of the transverse process. The tip was then directed infero-medially, and the needle was advanced into the “safe triangle” of the L4-L5 transforaminal space. Proper needle position was then confirmed by multiple fluoroscopic views. An aspiration test was negative for blood, CSF, and other fluids. Thereafter, 0.5 mL of contrast was slowly injected (without incident) under live fluoroscopy and imaging revealed medial spread of the dye along the nerve root, and into the epidural space. No vascular uptake was noted. The steroid with preservative-free normal saline in a total volume of 1.5 mL was then slowly injected with ease and without incident.

The needle was removed and a transforaminal injection was then performed at {{L5-S1}}, on the left, with the same results and without complications. Injection of contrast dye under live fluoroscopy (to confirm medial spread along the nerve root and into the epidural space) was performed at each treated nerve.

The total dose of dexamethasone given was 10 mg. Total fluoroscopy time was {{}} minutes ({{}}mGy).

The procedure was performed uneventfully and was well-tolerated by the patient. The patient was transferred to an observation room and recovered without incident. 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.