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I've seen some folks talk about things like this lately......so I had the Docs send me my report as it was done not long after my brain surgery so I forgot exactly what was done...but what the issue was..in my words....worst pain I have ever felt and could not sit on my ass... ...here is what the issue is medically and what was done. 
Hope it helps...and by the way...like I said in another post....going on 9 months since done and I don't have one issue..but like I said TRT has to be helping as I don't think it would just go away!
DATE OF PROCEDURE: 03/09/2018
PREP & POST-PROCEDURE DIAGNOSES
1. Left L4-L5 radiculitis/radiculopathy.
2. Multilevel lumbar degenerative disc disease at L4-L5 and L5-S1 with associated foraminal stenosis.
PROCEDURE PERFORMED
Left L4-L5, L5-S1 transforaminal epidural steroid injection under fluoroscopic guidance with local anesthesia, lidocaine 1%.
INDICATIONS FOR SURGERY
50-year-old female, who has had persistent low back, left buttock, and left calf pain in the setting of L4-L5 degenerative disc disease with associated foraminal stenosis. Her pain has been quite debilitating and severe. She is unable to sleep. She is also currently undergoing workup and treatment for metastatic brain cancer. Her back pain has been quite severe and is currently occupying most of her time, although she has several physician appointments with regard to her metastatic brain cancer. She is here today for a lumbar epidural steroid injection.
PROCEDURE IN DETAIL
Using fluoroscopic guidance, a 25-gauge 3.5-inch spinal needle was advanced under the pedicles in the 6 o'clock position for the left L4-L5 neural foramen. Under lateral fluoroscopic guidance, the needle was advanced slowly into the upper third of the intervertebral foramen to remain in the safe zone. Needle placement was confirmed in the AP, lateral, and oblique views and was found to be satisfactory. After pulling back on the syringe plunger to assure that no blood or cerebrospinal fluid was seen, 1 mL of Isovue-M 300 was injected intothe site to confirm needle placement. There was no proximal vascular, subdural, or subarachnoid flow. The contrast outlined the neural foramen with excellent epidural spread.
New bottles of sterile medications were used to perform an injectable of 1 mL of methylprednisolone 80 mg/mL plus 3 mL of bupivacaine 0.25%
preservative-free for a total of 4 mL. Then, 2 mL of the solution was injected gently into the site without difficulty.
The patient tolerated the procedure well. Signs and symptoms were monitored for pain reproduction or resolution. Fluoroscopic images were obtained to document spread of contrast material and needle position. Based on the patient's presentation, history and physical examination and other findings, I certify that the above services were medically necessary.
Hope it helps...and by the way...like I said in another post....going on 9 months since done and I don't have one issue..but like I said TRT has to be helping as I don't think it would just go away!DATE OF PROCEDURE: 03/09/2018
PREP & POST-PROCEDURE DIAGNOSES
1. Left L4-L5 radiculitis/radiculopathy.
2. Multilevel lumbar degenerative disc disease at L4-L5 and L5-S1 with associated foraminal stenosis.
PROCEDURE PERFORMED
Left L4-L5, L5-S1 transforaminal epidural steroid injection under fluoroscopic guidance with local anesthesia, lidocaine 1%.
INDICATIONS FOR SURGERY
50-year-old female, who has had persistent low back, left buttock, and left calf pain in the setting of L4-L5 degenerative disc disease with associated foraminal stenosis. Her pain has been quite debilitating and severe. She is unable to sleep. She is also currently undergoing workup and treatment for metastatic brain cancer. Her back pain has been quite severe and is currently occupying most of her time, although she has several physician appointments with regard to her metastatic brain cancer. She is here today for a lumbar epidural steroid injection.
PROCEDURE IN DETAIL
Using fluoroscopic guidance, a 25-gauge 3.5-inch spinal needle was advanced under the pedicles in the 6 o'clock position for the left L4-L5 neural foramen. Under lateral fluoroscopic guidance, the needle was advanced slowly into the upper third of the intervertebral foramen to remain in the safe zone. Needle placement was confirmed in the AP, lateral, and oblique views and was found to be satisfactory. After pulling back on the syringe plunger to assure that no blood or cerebrospinal fluid was seen, 1 mL of Isovue-M 300 was injected intothe site to confirm needle placement. There was no proximal vascular, subdural, or subarachnoid flow. The contrast outlined the neural foramen with excellent epidural spread.
New bottles of sterile medications were used to perform an injectable of 1 mL of methylprednisolone 80 mg/mL plus 3 mL of bupivacaine 0.25%
preservative-free for a total of 4 mL. Then, 2 mL of the solution was injected gently into the site without difficulty.
The patient tolerated the procedure well. Signs and symptoms were monitored for pain reproduction or resolution. Fluoroscopic images were obtained to document spread of contrast material and needle position. Based on the patient's presentation, history and physical examination and other findings, I certify that the above services were medically necessary.
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