Epidural Steroid Injection Procedure Note

Date/Time: [Procedure date and time]

Facility/Location: [Facility name and procedure suite/location]

Patient Name: [Full name]

DOB: [Date of birth]

MRN: [Medical record number]

Performing Clinician: [Clinician name, credentials]

Procedure: Epidural Steroid Injection — [caudal / interlaminar / transforaminal] approach

Target Level(s) and Side(s): [Vertebral level(s)] — [left / right / bilateral]

Imaging Modality: [fluoroscopy / CT / ultrasound] [Rationale if ultrasound used]

Sedation: [Sedation level] — [Agent(s) and dose(s)] (Include only if sedation beyond local anesthesia was used; otherwise omit this line entirely)

Procedure Synopsis

[Procedure performed with approach, specific level(s), and laterality]. [Primary indication/diagnosis]. [Imaging modality and contrast confirmation statement including vascular/intrathecal uptake status]. [Injectate summary: steroid name and dose, local anesthetic name with concentration and volume, total volume]. [Pre-procedure pain score with named scale (e.g., NRS 0–10) and immediate post-procedure pain score using same scale]. [Immediate complications or "no complications".] (Write as a single narrative paragraph of 3–6 sentences that stands alone as a complete clinical summary)

Indication & Medical Necessity

Primary Indication: [radiculopathy/radicular pain / neurogenic claudication / post-laminectomy syndrome / other]

Symptom Description: [Pain pattern, laterality, distribution consistent with target level(s)]

Pertinent Imaging: [Imaging modality] dated [date] showing [relevant finding(s)]

Conservative Treatment: [Therapies tried with durations and outcomes; or reason conservative care not feasible]

Prior ESI History: [Date, approach, level/side, response, duration of benefit] (If none, state "No prior ESI in this region." If complete evaluation documented elsewhere, may reference: "See pain clinic note dated [date] for full evaluation.")

Pre-Procedure

• Informed Consent: [Consent obtained. Risks discussed including rare serious neurologic events. Benefits, alternatives, and off-label nature of epidural steroid use reviewed. Questions answered. Patient agreed to proceed.]
• Time-Out Confirmed: [Correct patient, procedure, level/side, and positioning verified. Allergies reviewed. Anticoagulation plan verified. Imaging available. Team members present: [names/roles].]
• Baseline Pain Score: [Numeric score] on [named scale, e.g., NRS 0–10]
• Anticoagulation Status: [No anticoagulant or antiplatelet therapy] or [Agent(s), last dose date/time, held per guideline: yes/no]
• Relevant Safety Considerations: [Contrast allergy and mitigation plan / Pregnancy status / Diabetes and hyperglycemia counseling / Active infection concern] (Include only if applicable; omit this item entirely if none apply)

Procedure Details

[Patient positioning]. Skin prepared with [prep agent] and draped in sterile fashion. [Local anesthetic agent, concentration, volume] infiltrated at planned entry site.

(Complete only one approach section per injection site; delete the others)

Caudal Approach

Using [fluoroscopy / ultrasound / CT], the sacral hiatus was identified. A [needle gauge and type] was advanced through the sacrococcygeal ligament into the caudal epidural space. Contrast ([agent], [volume]) was injected, demonstrating [epidurogram pattern] consistent with appropriate epidural distribution. Intravascular uptake: [absent / present — needle repositioned, repeat contrast confirmed epidural spread / procedure aborted]. [Catheter details if used: advanced to [level], [size/type]].

Interlaminar Approach

The [interlaminar space, e.g., L4–L5] was accessed via [midline / paramedian] approach under [fluoroscopy / CT / ultrasound] guidance. A [needle gauge and type] was advanced to the ligamentum flavum, and loss-of-resistance to [air / saline] confirmed epidural entry. Contrast ([agent], [volume]) was injected with [epidural spread pattern] observed. Intravascular or intrathecal uptake: [absent / present — needle repositioned, repeat contrast confirmed epidural spread / procedure aborted]. Final needle tip location: [epidural space at specified level].

Transforaminal Approach

Target: [level(s)] — [left / right / bilateral]. Under [fluoroscopy / CT], a [needle gauge and type] was advanced along [safe triangle / subpedicular / inferior foramen] trajectory using [AP / oblique / lateral] landmarks to [target foramen/nerve root region]. Test contrast ([agent], [volume]) injected prior to therapeutic injectate. Vascular uptake detection: [real-time fluoroscopy / digital subtraction angiography]. Intravascular uptake: [absent / present — needle repositioned and repeat contrast confirmed perineural spread / procedure aborted]. Aspiration: [negative / positive]. (Aspiration does not replace contrast confirmation.)

Imaging views obtained: [AP / lateral / oblique]. Images documenting final needle position and contrast flow saved per facility policy. Fluoroscopy time: [time] (if tracked).

Injectate

• Contrast: [Agent name], [volume]
• Steroid: [Name], [particulate / non-particulate], [dose in mg] (If omitted, state reason, e.g., "diagnostic block only")
• Local Anesthetic: [Name], [concentration], [volume]
• Total Volume: [Total volume delivered at this site]

(If exact doses unavailable at documentation, note "See MAR for exact dose" and ensure reconciliation)

Complications

[None. Procedure completed without complication.] or [Complication: [description] — Intervention: [management and outcome]] (This field must never be left blank or omitted)

Post-Procedure Assessment

• Immediate Post-Procedure Pain Score: [Numeric score] on [same named scale as baseline]
• Percent Pain Relief: [Percent] (if practice tracks this metric; otherwise omit)
• Monitoring & Discharge: [Monitoring period]. Vital signs [stable / other]. [Ambulatory at discharge].
• Discharge Instructions: Provided. Red-flag symptoms reviewed: fever, severe headache, progressive weakness or numbness, bowel/bladder changes.
• Anticoagulant Resumption: [Timing and agent] (Include only if applicable)
• Follow-Up: [Timeframe and plan]

Signature

[Performing clinician signature], [credentials] — [Date/Time]