Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
CPT4 code
Name of the Procedure:
Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, each additional level
Summary
This procedure involves injecting an anesthetic and/or steroid into the spinal epidural space at the cervical (neck) or thoracic (upper back) levels, using imaging guidance like fluoroscopy or CT. This injection helps to alleviate pain and inflammation in the affected area.
Purpose
Medical Conditions Addressed:
- Herniated discs
- Spinal stenosis
- Radiculopathy (pinched nerve)
- Chronic neck or upper back pain
Goals/Outcomes:
- Reduce pain and inflammation.
- Improve mobility and function.
- Delay or prevent the need for surgery.
Indications
Symptoms/Conditions:
- Severe or persistent neck or upper back pain radiating to arms or shoulders.
- Nerve pain that hasn’t responded to conservative treatments.
- Conditions confirmed by MRI, CT, or other diagnostic imaging.
Patient Criteria:
- Chronic pain unresponsive to other treatments like physical therapy or medication.
- Diagnosis confirmed by imaging studies.
- Medically fit for the procedure.
Preparation
Pre-procedure Instructions:
- Fasting for at least 6 hours prior to the procedure.
- Stopping certain medications (e.g., blood thinners) as directed by your physician.
- Arranging for someone to drive you home after the procedure.
Diagnostic Tests:
- MRI or CT scan to identify the exact location for injection.
Procedure Description
- The patient is positioned on a procedure table.
- Local anesthesia is applied to the skin to numb the injection site.
- Using fluoroscopy or CT guidance, a needle is carefully inserted into the targeted epidural space.
- A contrast dye may be injected first to confirm correct needle placement.
- Anesthetic and/or steroid medication is slowly injected.
- The needle is removed, and the injection site is cleaned and covered.
Tools and Technology:
- Fluoroscopy or CT scanner
- Sterile needles and syringes
- Anesthetic and steroid medications
- Contrast dye (if needed)
Anesthesia:
- Local anesthesia at the injection site. Sedation may be provided if necessary.
Duration
The procedure typically takes about 30 to 60 minutes.
Setting
Typically performed in a hospital, outpatient clinic, or surgical center equipped with imaging technology.
Personnel
- Interventional radiologist or anesthesiologist
- Nurse
- Radiologic technologist
Risks and Complications
Common Risks:
- Temporary increase in pain
- Infection at the injection site
- Bleeding
Rare Complications:
- Nerve damage
- Dural puncture leading to headache
- Allergic reaction to medications
Management:
- Close monitoring post-procedure
- Immediate treatment of any adverse reactions or complications
Benefits
Expected Benefits:
- Pain relief within a few days to a week
- Reduced inflammation
- Improved function and quality of life
Recovery
Post-procedure Care:
- Rest for the remainder of the day.
- Avoid heavy lifting and strenuous activities for several days.
- Follow-up appointment to assess the effectiveness.
Recovery Time:
- Most patients can resume normal activities within a few days.
Restrictions:
- Avoid driving or operating machinery for at least 24 hours post-procedure.
Alternatives
Other Treatments:
- Physical therapy
- Medications (e.g., pain relievers, anti-inflammatories)
- Surgery (in severe cases)
Pros and Cons:
- Physical therapy and medications are less invasive but may be less effective.
- Surgery may provide more permanent relief but comes with higher risks and longer recovery.
Patient Experience
During the Procedure:
- Mild discomfort or pressure at the injection site.
- Usually well-tolerated due to local anesthesia.
Post-procedure:
- Some temporary pain increase before relief sets in.
- Pain relief and improved function typically occur within a few days.