Date of Procedure: 6/12/2021
Procedure name: Cervical epidural steroid injection
Level: C7/T1
Injectate: 5 mg dexamethasone, 4 ml NS
Pre-op diagnosis: Radiculopathy, cervical region M54.12
Post-op diagnosis: Radiculopathy, cervical region M54.12
CPT: 62321 CESI/TESI
The procedure was explained to the patient and ample time was provided for questions/answers. Risks, benefits and alternatives were explained and discussed and informed consent was obtained.
The patient's identity, the procedure to be performed and the specific site of the procedure was verified.
PRE-PROCEDURE VERIFICATION: The patient confirmed their name and date of birth; confirmed correct patient, procedure, consent, positioning, side/site, blood products and special equipment (as applicable)
PROCEDURE SITE WAS MARKED or Not required for obvious wound/lesion, midline, single organ procedures, procedures without intended laterality (e.g., endoscopes and colposcopies) or procedures in which there are no predetermined sites of insertion or the patient is awake and the provider is with the patient at all times.
A TIME-OUT WAS PERFORMED immediately before the procedure noting the above as well as confirming the patient's position, relevant images and labs, antibiotics, fluids, and safety precautions.
The patient was positioned comfortably in the prone position and prepped in the normal sterile fashion. Site/landmarks were identified with the assistance of fluoroscopy.
A mark was made at the skin over the interspace of C7/T1 and lidocaine 1% w/o epinephrine was injected subcutaneously.
An epidural tuohy needle was advanced to epidural space using loss of resistance technique with saline solution. Placement was confirmed with injection of 1ml of contrast media and oblique fluoroscopy. After no CSF or blood was aspirated, a solution containing the injectate (above) was slowly and carefully injected.
The patient tolerated this procedure well and vitals were as pre-op. After being transported to the recovery room, post procedure risks and instructions were reviewed by nursing staff.
The patient was released with a driver after demonstrating the ability to ambulate without difficulty and remaining discharge criteria were met.
Sarah Bright 5/13/2025 7:18 pm