Caudal Epidural Steroid Injection

Procedure Note – Caudal Epidural Steroid Injection

PATIENT:  ____________________

PHYSICIAN:  Physician Name

DIAGNOSIS:  _______________

DATE OF PROCEDURE:  ____________

PROCEDURE:  Caudal Epidural

The patient/family member has been informed of the risks and the benefits of the planned procedure.

In the fluoroscopy room the patient was placed in a prone position and the skin over the lumbosacral spine including the gluteal cleft was prepped and draped in a sterile manner.  The sacral curve was identified under fluoroscopy.  The sacral cornu was identified by palpation.  The skin and deeper tissues were numbed with 0.5% lidocaine.  The caudal epidural space was accessed with a 22 G 3½ inch spinal needle via the sacral cornu.  Loss of resistance was obtained.  2 cc of Omnipaque was injected.  The dye was seen to spread along the sacral epidural space.  Then 18 cc of 1/8 bupivacaine and 80 mg of methylprednisolone was injected.

Patient tolerated the procedure very well.

Complications:  None.

Full discharge instructions were given to the patient.  The patient was discharged in a stable condition.

__________

Physician Name