Spine Injection Procedure Note (Epidural/Facet/Medial Branch Block)

Date/Time: [Start time and stop time]

Location: [clinic / ASC / hospital]

Performing Clinician: [Name, credentials]

Assistant(s): [Name(s) and role(s) / None]

Procedure Performed

• Procedure type: [Epidural steroid injection – interlaminar / transforaminal / caudal / Facet joint injection – intra-articular / Medial branch block] ([diagnostic / therapeutic])
• Spinal region: [cervical / thoracic / lumbar / sacral]
• Laterality: [left / right / bilateral / midline]
• Level(s): [Specific level(s) using standard notation, e.g., L4-5, L5-S1, L3 and L4 medial branches]
• Imaging guidance: [fluoroscopy / CT / ultrasound]
• Pre-procedure diagnosis: [Diagnosis]
• Post-procedure diagnosis: [Diagnosis] (If unchanged, state "same as pre-procedure.")

Indication and Medical Necessity

[Narrative description of pain generator hypothesis and symptom pattern] (State whether pain is radicular or axial/facet-mediated; specify if procedure is diagnostic or therapeutic. Include symptom duration, severity, and functional impact.)

Baseline pain score: [Numeric value] on [Named validated scale, e.g., 0–10 NRS, VAS]

(For confirmatory medial branch block: Reference date and result of prior diagnostic block, including percent relief and duration.)

Conservative management history: [Therapies attempted, duration of trials, and reason response was inadequate]

Imaging reviewed: [Modality, date, and specific findings at target level(s) correlating with symptoms] (For cervical procedures, document that imaging confirmed adequate anatomy and safe trajectory.)

Rationale for selected level(s)/laterality: [Explanation based on symptom-imaging-exam correlation] (If multiple levels targeted, specify why a single level is insufficient.)

Pre-Procedure Assessment

• Allergies: [Relevant allergies with reaction type / None known] (Include local anesthetics, steroids, iodinated contrast, latex.)
• Anticoagulation/Antiplatelet status: [Agent(s)] | Last dose: [Date/time] | Held: [yes / no] | Holding instructions by: [Name/service] | (If continued, document risk-benefit rationale. This must be explicitly addressed—do not infer from medication list.)
• Infection screening: Fever/systemic illness: [present / absent] | Local skin infection at site: [present / absent]
• Pregnancy status: [Not applicable / Negative / Positive] (Document when applicable, especially if fluoroscopy used.)
• Neurologic baseline: New or progressive weakness: [present / absent] | Bowel/bladder symptoms: [present / absent]
• Sedation plan: [none / minimal / moderate] (If moderate sedation: document necessity justification, NPO status, escort confirmed, and monitoring plan.)

Consent and Time-Out

Informed consent obtained. Risks discussed included bleeding/hematoma, infection, allergic reaction, temporary numbness/weakness, increased pain, and dural puncture/headache for epidural approaches. (For epidural steroid injection: Document that rare serious neurologic complications were discussed and that epidural corticosteroid use is off-label.) Alternatives and option of no procedure discussed; questions answered; patient agreed to proceed.

Time-out completed confirming correct patient identity, correct procedure, correct side and level(s), allergies reviewed, anticoagulation status acknowledged, and imaging available.

Technique

(Ensure levels and laterality are explicitly restated in this section.)

1. Positioning: [Prone / Lateral decubitus / Sitting]
2. Skin prep and sterility: [Prep solution] applied; sterile technique with [mask, cap, sterile gloves, sterile drape].
3. Local anesthesia: [Agent, concentration, volume] infiltrated at [level(s) and laterality].
4. Needle and approach: [Needle type, gauge, length] advanced via [approach] at [level(s) and laterality].
5. Imaging guidance: [Fluoroscopy / CT / Ultrasound]; [AP / lateral / oblique] views obtained to confirm needle position. Images saved to PACS/EMR.
6. Contrast: [Used / Omitted]
   • (If used: State agent and volume. Document observed pattern confirming correct placement and absence of intravascular uptake.)
   • (If omitted: State reason and alternative confirmation method.)
7. Aspiration: [Negative for blood/CSF / Positive – describe management]
8. Epidural-specific (if applicable):
   • Loss-of-resistance technique: [air / saline]
   • Epidural spread pattern: [Description]
   • (For transforaminal: Document steroid type [particulate / non-particulate]; non-particulate required for cervical.)
9. Facet intra-articular (if applicable): Arthrogram pattern confirming joint entry observed.
10. Medial branch block (if applicable): Nerve targets: [Specific nerves, e.g., L3 medial branch, L4 medial branch]. Small-volume technique: [volume per target].
11. Radiation metrics: Fluoroscopy time: [seconds] | Dose: [mGy or Gy·cm²] (If not available, state "not captured due to device limitation." Omit if ultrasound-guided.)

Injectate

(List each injection site with exact level and laterality.)

• Site 1: [Level and laterality]
  • Local anesthetic: [Agent, concentration, volume]
  • Steroid (if used): [Agent, dose in mg, volume]
• Site 2: [Level and laterality] (Add additional sites as needed.)
  • Local anesthetic: [Agent, concentration, volume]
  • Steroid (if used): [Agent, dose in mg, volume]

Total volume delivered: [Total mL] (excluding contrast)

Contrast (if tracked separately): [Agent, total volume]

Post-Procedure Status and Disposition

• Tolerance: [Well tolerated / Tolerated with noted issues]
• Complications: [None / Description and management]
• Neurologic reassessment: Strength and sensation [unchanged from baseline / specify changes]
• Post-procedure pain score: [Numeric value] on [Same scale as baseline]
• Disposition: [Discharged home / Other] (If sedation used, confirm escort present and driving restrictions provided.)
• Instructions provided: Post-procedure instructions reviewed including activity restrictions and red flag symptoms (progressive weakness, bowel/bladder changes, severe positional headache, fever, worsening pain). (For held anticoagulation: Document resumption timing provided. For steroid injection: Include steroid-related effects discussed.)

Follow-Up Plan

Follow-up: [Phone / Portal / In-person] in [timeframe]. Outcomes to assess: percent pain relief compared to baseline, functional improvement, and duration of benefit.

(For diagnostic medial branch blocks: Include pain diary instructions with time windows to record onset, peak relief, and duration of response.)

Conditional next steps: [Plan if inadequate response; plan if diagnostic block positive, e.g., confirmatory block or radiofrequency ablation evaluation]

(If diary-based or delayed outcome data will be captured, note that an addendum will be added with date and linkage to index procedure.)