Caudal Epidural Steroid Injection

PROCEDURE:  The patient was placed prone.  The sacral hiatus area was prepped with Betadine.  Skin and subcutaneous tissues over the sacral hiatus area were anesthetized with 2 cc of 1% lidocaine with a 27-gauge needle.  A 22-gauge sheathed needle was advanced to the sacral hiatus using a nerve stimulator.  The epidural space was localized and Celestone 12 mg, fentanyl 50 mcg, and Sensorcaine 0.06% 30 cc was given in the epidural space.  The patient tolerated the procedure well.

Facet Joint Injection

PROCEDURE IN DETAIL:  The patient was placed prone on the fluoroscopy table. The skin over the right L3-4 and L4-5 facets was localized with fluoroscopic guidance.  The beam was obliqued slightly rightward.  The skin was prepped and draped in sterile fashion.  The skin was anesthetized with a small amount of 1% lidocaine.  With fluoroscopic guidance, a 3-1/2-inch 22-gauge spinal needle was placed at the right L3-4 facet joint.  Contrast injection confirmed placement.  The joint was subsequently injected with a total of 2 cc of a mixture of 3 cc of 1% lidocaine and 1 cc of Celestone 6 mg/ml.  The needle was withdrawn. Subsequently, a 3-1/2-inch 22-gauge needle was placed at the right L4-5 facet joint.  Placement of the needle did not provoke any pain.  Contrast injection confirmed placement.  The area of the joint was injected with 2 cc of the above Celestone/lidocaine mixture.  The needle was withdrawn. The patient was monitored in the radiology department after the injection.

Lumbar Epidural Steroid Injection

TECHNIQUE:  The patient was placed in the left lateral decubitus position with peripheral IV, O2 by nasal cannula, and monitors.  His back was prepped and draped in sterile fashion.  Lidocaine 1% was used for a skin wheal.  An 18-gauge Hustead needle was introduced at the L3-4 interspace with loss of resistance to air at 8 cm on the first pass.  There was no blood, CSF or paresthesias noted during the procedure.  There was a negative test dose with 3 cc of 1% lidocaine.  A total volume of 13 cc of steroid solution was incrementally injected with no change in blood pressure.  This consisted of 80 mg of Kenalog, 50 mcg fentanyl, and 10 cc preservative-free normal saline. The needle was withdrawn and the back was cleaned.  A Band-aid was applied.  


PROCEDURE IN DETAIL:  After an IV was started, the patient was sedated with 0.5 mg Versed and 0.5 cc fentanyl. She was turned in the left lateral decubitus position and the lumbosacral area was prepped with Betadine, draped, and allowed to dry.  The skin and subcutaneous tissues over the L3-4 interspace were anesthetized with 1% Xylocaine in the paramedian position.  An epidural needle was placed into the epidural space paramedian at that level.  Aspiration was negative for CSF and blood. There was no pain or paresthesias with placement of the needle or with injection of a solution containing 80 mg Kenalog, 3 cc 0.25% bupivacaine, 50 mcg fentanyl, and 6 cc of preservative-free normal saline.  The needle was withdrawn.  Hemostasis was obtained.  The area was bandaged.

Nerve Root Block

PROCEDURE IN DETAIL:  The patient was placed prone on the fluoroscopy table. The fluoroscopy beam was obliqued slightly rightward in order to best localize the facet joint.  The skin was prepped and draped in sterile fashion.  The skin was anesthetized with a small amount of 1% lidocaine. With fluoroscopic guidance, a 3-1/2-inch 22-gauge spinal needle was placed at the inferior aspect of the neural foramen on the right at L5-S1.  Placement of the needle provoked a component of the patient's typical pain.  Contrast injection showed spread laterally and a small amount medially.  The area was then injected with a total of 2.5 cc of a mixture of 1 cc of Celestone 6 mg/ml, 2 cc of 1% lidocaine, and 1 cc of normal saline.  The patient tolerated the injection well.  The needle was withdrawn.