BWH Pain Attending Preferences

Dr. Srdjan Nedeljkovic

• Writes his own procedure notes and does his own telehealth and virtual visits
• Sometimes “runs the list” of clinic patients with you in the AM
• Always try to order 5 ml vial of Depo-Medrol if available except for TPIs (specifically order 200 mg otherwise defaults to multiple 1 ml vials)
• Punctual with clinic and procedures
• Wear a mask for procedures
• Weekend call: meet ~ 6:30 AM without pre-rounding
• Stays in hospital until morning notes are completed

• Baclofen Single Shot (with Fluoroscopy)

• Medications to Order: Baclofen 50 to 75 mcg/ml (Confirm dose with attending)
• Procedure: Spinal kit with 25 G Whitacre

Caudal Epidural Steroid Injection

• Medications to Order:
• Lidocaine 0.5% (50 mL)
• Omnipaque
• Depo-Medrol 40 mg/mL (5 mL vial)
• Procedure:

• #17 gauge Weiss needle
  • Inserts catheter midline to ~ L5 or S1
  • Confirmation with contrast in lateral + AP views
• Inject 120 mg methylprednisolone followed by 3 mL 0.5% lidocaine

Cervical Epidural Steroid Injection

• Medications to Order:
• Lidocaine 0.5% (50 mL)
• Depo-Medrol 40 mg/mL (5 mL vial)
• Procedure:

• Contralateral oblique view
• LOR to air with glass syringe
• Attach tubing to epidural needle and drip to gravity through glass LOR syringe
  • Administer 120 mg methylprednisolone followed by 3 mL 0.5% lidocaine

Cervical Medial Branch Block

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• Patient prone (A-P mid-point of articular pillar)
• Injectate (per level): 20 mg Depo-Medrol + 1 mL 0.25% bupivacaine
• 3.5 inch 22-gauge spinal needle

Genicular Nerve Block:

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate: 40 mg Depo-Medrol + 4 mL 0.25% bupi at each of the 3 levels

Intercostal:

2 bupi 2 steroid at each level

Usually fluoro but can be U/S, he does both

Knee Intra-Articular Steroid

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate: 6 mL 0.25% bupivacaine + 80 mg Depo-Medrol
• Fluoroscopy with 3.5 inch spinal needle

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Procedure:

• #17 gauge Weiss needle
• LOR to air with glass syringe
• Confirmation in CLO and lateral views without contrast
• Attach tubing to epidural needle and drip to gravity through glass LOR syringe
  • Administer 120 mg methylprednisolone mixed with 3 mL 0.5% lidocaine, then draw up 3cc of lido to chase the mixture in 3cc syringe after drip to gravity

Lumbar Medial Branch Blocks

Medications to Order:

0.5% lidocaine (50 mL)

0.25% bupivacaine (10 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Procedure:

• #22 gauge 3-½ inch spinal needle
• Injectate: 1 mL of 0.25% bupivacaine + 20 mg methylprednisolone at each level
  • Inject methylprednisolone then bupivacaine separately
• AP-only

Lumbar Radiofrequency Ablation:

Medications to Order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL)

Procedure:

Lumbar Transforaminal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg

Bupivacaine 0.25% (10 mL)

Contrast

Procedure:

• Pointer initially in AP at lateral inferior edge of transverse process
• Transition from AP to oblique with pointer in place
• Bent 22-gauge 3.5 inch spinal needle
• Injectate: 5 mg dexamethasone + 1 mL 0.25% bupivacaine per level

Sacroiliac Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial) > does 120

Bupivacaine 0.25% (10 mL)

Procedure:

• Medial to lateral approach (intra-articular)
• If unilateral, three #22-gauge 3-½ inch spinal needles (superior; middle; inferior pole)
  • 40 mg Depo-Medrol and 3 mL 0.25% bupivacaine into each needle
• If bilateral, two #22-gauge 3-½ inch spinal needles (midde; inferior pole) each side
  • 30 mg Depo-Medrol and 3 mL 0.25% bupivacaine into each needle

Shoulder Injection with Fluoroscopy

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL

Bupivacaine 0.25% (10 mL)

Procedure (Glenohumeral):

• Lateral to medial approach
• #22-gauge 3-½ inch spinal needle
• Injectate: 40 mg Depo-medrol + 5 mL 0.25% bupivacaine

Procedure (Acromioclavicular):

• #25-gauge 1-½ inch local needle
• Injectate: 40 mg Depo-medrol + 1 mL 0.25% bupivacaine

Sphenopalatine Ganglion Block

Medications to Order:

Bupivacaine 0.5%

Procedure:

• Cotton swab

TAP Block (Ultrasound)

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate: 18 mL 0.25% bupivacaine + 80 mg Depo-Medrol
• Needle insertion (Pajunk) from medial to lateral

Trigger Point Injections

Medications to Order:

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg/mL (1 mL vial)

Procedure:

• Injectate: 1 mL methylprednisolone (40 mg) + 9 mL 0.25% bupivacaine

Dr. Pritesh Topiwala

- Prefers help with telehealth and sometimes with virtual visits

- For Hale - 1st floor Daniel Ponton Teaming Room

- For procedure notes, copy forward prior progress note and add procedure note

- For progress notes, often keeps prior “Interval History”

- For FXB, order fluoroscopy with meds

Confirm availability of Depo-Medrol

Exchange bupivacaine 0.25% 1:1 with ropivacaine 0.5%

Caudal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

80 mg Depo-Medrol

Procedure:

• Injectate: 5 mL 0.5% lidocaine + 80 mg Depo-Medrol
• Attempts amLess with 25 G 1.5 inch “local” needle
• Confirms with contrast

Cervical Medial Branch Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg/mL (1 mL vial)

Procedure:

• #25 gauge spinal needle
  • Single needle x3 positions
• Lateral positioning for diagnostic blocks
• 0.75 mL injectate per position (injectate consists of 1 mL dexamethasone and 1.5 mL 0.5% lidocaine)

Genicular Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

60 mg Depo-Medrol

Procedure:

• Injectate: 20 mg Depo-Medrol + 1 mL 0.25% bupivacaine per site

Knee Intra-Articular Steroid with Fluoroscopy

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

40 mg Depo-Medrol or 40 mg Kenalog

Procedure:

• Pointer needle
• Use 1.5 inch 25-gauge local needle if amLess to joint if feasible
• Confirm with lateral fluoroscopy
• Injectate: 3 mL 0.25% bupivacaine + 1 mL steroid (40 mg Depo or 40 mg Kenalog)

Greater Trochanteric Bursa Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Palpation landmark technique
• Injectate: 40 mg Depo-Medrol + 4-6 ml 0.25% bupivacaine

Hip Intra-articular Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Supine fluoroscopy  
• Injectate: 40 mg Depo-Medrol + 4-6 ml 0.25%

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque 300 mg

Procedure:

• Loss-of-resistance to 3 mL contrast syringe
• Injectate: 80 mg Depo-Medrol + 3 ml 0.5% lidocaine

Lumbar Medial Branch Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque 300 mg

Procedure:

• 22-gauge 3.5 inch spinal needle
• - Injectate: 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine (1 mL per level)

Lumbar Transforaminal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg (1 mL)

Procedure:

• 22-gauge 3.5-inch needle
• Injectate: 1 mL 0.5% lidocaine + 10 mg (1 mL) dexamethasone per level

Sacroiliac Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

80 mg Depo-Medrol

Procedure:

• Injectate: 3 mL 0.25% bupivacaine + 40 mg Depo-Medrol
• Intra-articular approach

Trigger Point Injections

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

40 mg Depo-Medrol or 40 mg Kenalog

Procedure:

• Injectate: 5 mL 0.5% lidocaine + 5 mL 0.25% bupivacaine + 10 mg Depo-Medrol

Dr. Edward Michna

- Do not bend spinal needles

- Does his own telehealth and virtual visits

- Will see opioid refills alone and usually  marks his initials

- No lidocaine in epidural space (steroid and normal saline only)

Caudal Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (80 mg total)

Omnipaque 300 mg

Procedure:

• 17 G epidural needle (no catheter)
• + Contrast
• Large volume injectate ~ 8-10 ml total (6-8mL NS + 80 Depo-Medrol)

Cervical Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (80 mg total)

NO OMNIPAQUE

Procedure:

• Hanging drop technique with patient in sitting position (lateral fluoroscopy)
  • Prepare 3-mL syringe with normal saline and needle to add “drops” to epidural needle

• Attach tubing to epidural needle (preferably assistant so that the operator maintains control of needle)
• Drip to gravity through glass LOR syringe
  • 80 mg methylprednisolone followed by 2-3 mLs of normal saline

Cervical Medial Branch Blocks

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (80 mg total)

Procedure:

• Patient prone (A-P mid-point of articular pillar)
  • Confirmation in lateral view
• Injectate (per level): 20 mg Depo-Medrol + 1 mL 0.5% lidocaine
• 3.5 inch 22-gauge spinal needle

Genicular Nerve Block

Medications to Order:

Depo-Medrol 80 mg (2 mL)

Bupivacaine 0.25% (10 mL)

Lidocaine 0.5% (50 mL)

Procedure:

• Injectate: 20 mg Depo-Medrol + 2-3 mL 0.25% bupivacaine per level
• Superolateral + superomedial + inferomedial

Genicular RFA

Medications to Order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5cc)

Hip Injection: Greater Trochanteric Bursa

Medications to Order:

Depo-Medrol 40 mg (1 mL)

Bupivacaine 0.25% (10 mL)

Lidocaine 0.5% (50 mL)

Procedure:

• Injectate: 20-40 mg Depo-Medrol + 2 mL 0.25% bupivacaine per side

Knee Intra-Articular with Synvisc

Medications to Order:

Lidocaine 0.5% (50 mL)

Synvisc 2 mL (16 mg)

Procedure:

• Pointer needle
• Exchange local anesthetic needle for 3.5 inch 22-gauge spinal
• Confirm with lateral fluoroscopy, meet the osseous border

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (80 mg total)

Procedure:

• LOR to glass syringe with air (17 or 20 G epidural needle)
  • Lateral or CLO confirmation
  • No contrast

• Attach tubing to epidural needle
• Drip to gravity through glass LOR syringe
  • 80 mg methylprednisolone followed by 2-3 mLs of normal saline

Lumbar Medial Branch Blocks

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 60 mg per side (120 mg bilateral)

Procedure:

• 20 Depo-Medrol + 1 mL bupivacaine 0.25 ml each level
• Inject lidocaine with needle removal
• Confirm with lateral fluoroscopy

Lumbar Radiofrequency Ablation

Medications to Order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL)

Procedure:

• Cephalad tilt of fluoroscope (angled towards feet)
• One RFL lesion at a time
• Confirms RFL probes in lateral position
  • Multiple checks (ask patient to hold breath) with testing and 2% lidocaine

Lumbar Transforaminal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg (1 mL)

Procedure:

• 22-gauge 5-inch needle
• Injectate: 1 mL 0.5% lidocaine + 10 mg (1 mL) dexamethasone per level
• Do not bend needle

Sacroiliac Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: 2 mL bupivacaine 0.25% + 40 mg Depo-Medrol
• Single injection at inferior pole of joint
• Confirm with lateral fluoroscopy

Trigger Point Injections

He’s okay with you starting without him

Medications to Order:

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: 9 mL 0.25% bupivacaine + only 20mg Depo-Medrol (usually)
  • Varies injectate with frequency of TPIs and history of diabetes mellitus

[Dr. Ed Ross]

- Does his own telehealth and virtual visits

- Often sees patients on his own (and performs pump refills)

- High level of autonomy afforded to residents and fellows

Baclofen Single Shot

Medications to Order:

Baclofen 50 mcg/ml if ambulatory

Confirm dose with attending

Procedure:

• Sitting or lateral decubitus per patient comfort
• Spinal kit with 25 G Whitacre

Botulinum Toxin (BOTOX)

Medications to Order:

Botulinum toxin type A injection 100 units

Procedure:

• Doesn’t always use “migraine protocol”

Caudal Epidural Steroid Injection

Medications to order:

Lidocaine 0.5%

Methylprednisolone 40 mg/mL (80mg total)

Procedure:

• Injectate: 80 mg methylprednisolone + 3-4 mL 0.5% lido
• Can use 25 g 1.5 inch finder needle to amLess space (by palpation if possible) with fluoro to confirm or reposition
• No contrast

Cervical Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (80 mg total)

Procedure:

• Hanging drop technique with patient in sitting position (lateral fluoroscopy)

Cervical Medial Branch Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Methylprednisolone 80 mg

Procedure:

• Injectate (per level): 20 mg methylprednisolone + 0.5-1 mL 0.25% bupivacaine
• 25-gauge 2.5 inch needle
• AP fluoroscopy targeting pedicle

Greater Trochanteric Bursa Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• No fluoroscopy or contrast
• Injectate: 40 mg Depo-Medrol + 4 mL 0.25% bupivacaine

Hip Intra-Articular Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• Fluoroscopy with 22G 3.5 inch spinal needle
• Injectate: 40 mg Depo-Medrol + 4 mL 0.25% bupivacaine

Knee Intra-Articular Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Procedure:

• Landmark or fluoroscopy
• Injectate: 40 mg Depo-Medrol + 4 mL 0.25% bupivacaine

Lumbar Medial Branch Blocks

Medications to order:

Lidocaine 0.5% (50 mL)

Methylprednisolone 40 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• AP views only
• No specific injectate preference

Piriformis Injection

Medications to order:

Methylprednisolone 40 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• Landmark (palpation) technique
• Injectate: 10-20 mg methylprednisolone + 5 mL 0.25% bupivacaine

Pump Refill

Procedure:

• Use pump refill template

Sacroiliac Joint Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Methylprednisolone 40 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• AP views only
• Periarticular injection x2 (inferior pole and ~ ⅓ distance above inferior pole)
• Injectate: 10-20 mg Depo-Medrol + 1 mL 0.25% bupivacaine per needle

Thoracic Medial Branch Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Methylprednisolone 80 mg

Procedure:

• Injectate (per level): 20 mg methylprednisolone + 0.5-1 mL 0.25% bupivacaine
• 25-gauge 2.5 inch needle
• AP fluoroscopy targeting pedicle

Trigger Point Injections

Medications to Order:

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg/mL (1 mL)

Procedure:

• Injectate: 1 mL methylprednisolone + 9 or 10 mL 0.25% bupivacaine

Dr. Jason Yong

- Does his own telehealth and sometimes does his own virtual visits

Prefers help with telemedicine if “complete downtime”

- Writes his own procedure notes

- Writes his own operative notes

- For Faulkner - do not place medication orders

- For Hale - 1st floor Daniel Ponton Teaming Room

Botox for migraines

Caudal Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg (2 mL)

Procedure:

• Start with lateral image
• Injectate: 6 ml 0.5% lidocaine + 80 mg Depo-Medrol

Celiac Plexus Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Start AP to identify TP of L1 then ipsilateral (L) oblique until TP lines up with lateral edge of vertebral body
• Advance needle co-axial to lateral edge of L1 vertebral body and transverse process
• Advance through aorta (consider removing stylet to visualize blood) then advance again through back wall (i.e. through and through method)
• Injectate: 80 mg Depo-Medrol + 8-9 mL 0.25% bupivacaine (10 mL total)

Cervical Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Loss-of-resistance to 3 mL contrast syringe
• Confirmation in CLO view
• Injectate: 80 mg Depo-Medrol + 3 ml 0.5% lidocaine

Cervical Medial Branch Block

Medications to order:

Bupivacaine 0.25% or 0.5% (10 mL)

Dexamethasone 10 mg

Lidocaine 0.5% (50 mL)

Procedure:

• 4 levels with 1.5 inch 25-gauge local anesthetic needle (single needle technique)
• Lateral position
• Injectate: 10 mg dexamethasone + 3 mL 0.5% bupivacaine (1 mL per level)

Epidural ITP Trial (for non-malignant pain)

Medications to order:

• 0.0625% bupivacaine + 20 mcg/ml hydromorphone (confirm with Jason)

For the OR:

• Periflex catheter set (1.5% lido with epi and Chloraprep inside kit) + Epimed epidural needle (x2 if tunneling) + Epimed epidural catheter + StayFix
• C-arm + drape
• 1000 drapes + blue towels + ½ sheet

Post-op:

• Admit to ERU/23h inpatient for titration
• Start with 0.0625% bupivacaine + 20 mcg/mL hydromorphone at 6 mL/hr
  • If necessary to increase density, increase to 40 mcg/mL or 60 mcg/mL hydromorphone mix

Ganglion Impar

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Omnipaque

Procedure:

• Lateral fluoroscopy
• Confirm with contrast
• Injectate: 5 mL bupivacaine 0.25% + 40 mg Depo-Medrol

Knee Intra-Articular Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% (10 mL)

Procedure

• Landmark technique
• Injectate: 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine + 2 mL 0.5% lidocaine

Lumbar Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Loss-of-resistance to 3 mL contrast syringe
• Confirmation in CLO view
• Injectate: 80 mg Depo-Medrol + 3 ml 0.5% lidocaine (5 mL total volume)

Lumbar Medial Branch Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Single needle technique (bent) 22 or 25 gauge
• Injectate: 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine (1 mL per level)

Lumbar Radiofrequency Ablation

Medications to order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL)

Procedure:

• AP for SA needle then “Scotty dog”
• 2 minute lesion followed by 180 degree turn of needle then 2 minute repeat lesion

Lumbar Sympathetic Block

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% (10 mL)

Omnipaque

Procedure

• Injectate: 40 mg Depo-Medrol + 10 mL 0.25% bupivacaine

Occipital Nerve Block

Medications to order:

Lidocaine 2% (5 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: 1 ml 40 mg/ml Depo-Medr ol + 4 ml 2% lidocaine
• 30 gauge 0.5 inch needle
• 1 ml at each LONB, 1.5 ml at each GONB

Pump Refill

Procedure:

• Use ultrasound to identify refill port
  • Mark with marker or imprint skin with cap

Sacroiliac Joint Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• Target lateral border of S1 + S2 + S3 foramen and SA
• Two needles: first target S1 and S3 - second target SA and S2
• Injectate for unilateral: 40 mg Depo-Medrol + 3 mLs 0.5% bupivacaine (1 mLs each level)
• Injectate for bilateral: 80 mg Depo-Medrol + 7 mLs 0.5% bupivacaine

Stellate Ganglion Block

Medications to order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• Ultrasound-guided (in-plane)
• Injectate: 10 mg dexamethasone + 8-9 mL 0.25% bupivacaine

Transforaminal Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Dexamethasone 10 mg

Omnipaque

Procedure:

• Injectate: 10 mg dexamethasone + 1 mL 0.25% bupivacaine or 1 mL 0.5% lidocaine
  • If 2 levels, draw up 10 mg dex + 3 mL 0.25% bupivacaine for total of 2 mL at each level

Dr. Ehren Nelson

- Predominantly dexamethasone as steroid choice

- Prefers help with telemedicine and virtual visits

- For Faulkner - do not place medication orders

Cervical Epidural Steroid Injection

Medications to Order:

Dexamethasone 10 mg

Lidocaine 0.5% (50 mL)

Omnipaque

Procedure:

• Injectate: 10 mg dexamethasone + 3-4 mL 0.5% lidocaine
• LOR with contrast syringe
• 20-gauge Weiss needle

Cervical Medial Branch Block

Medications to Order:

Dexamethasone 10 mg

Lidocaine 0.5% (50 mL)

Procedure:

• Patient in lateral position (AP films) aim for middle of lateral mass
• Injectate (3 levels): draw up 10 mg dexamethasone + 1.5 mL 0.5% (or 2%) lidocaine → 3.3 mg dexamethasone + 0.5 mL 0.5% lidocaine at each level

Lumbar Epidural Steroid Injection

Medications to Order:

Dexamethasone 10 mg

Lidocaine 0.5% (50 mL)

Omnipaque

Procedure:

• Injectate: 10 mg dexamethasone + 3-4 mL 0.5% lidocaine
• LOR with contrast syringe
• 20-gauge Weiss needle

Transversus Abdominis Plane Block

Medications to Order:

Dexamethasone 10 mg

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate: 10 mg dexamethasone + 9 mL 0.5% bupivacaine
• Prepare two additional 5 mL syringes of 0.5% lidocaine

Shoulder Glenohumeral Joint Injection with Ultrasound (Posterior Approach)

Medications to Order:

Depo-Medrol 40 mg

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Procedure:

• Patient in prone or lateral position → place ultrasound on posterior shoulder to identify triangle
• Injectate: 40 mg Depo-Medrol + 3 mL 0.25% bupivacaine

Dr. Mo Issa

- For procedure notes, carry forward prior follow-up notes and embed procedure note

- For Faulkner - do not place medication orders

- Weekend call: Prefers pre-rounding (meet at ~ 8 or 9 AM)

- Contrast for: synvisc, LESI, (most things)

Cervical Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg

Omnipaque

Procedure:

• Injectate: 10 mg dexamethasone + 3 mL 0.5% lidocaine
• Loss of resistance to tubing + contrast

Cervical Medial Branch Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Lateral positioning if unilateral at higher than C5
  • Prone positioning if bilateral or C5 and lower
• Injectate: 10 mg dexamethasone + 2-3 mL 0.25% bupivacaine (1 mL per level)

Cluneal Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Target 3 points along iliac crest
• Injectate (therapeutic): 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine (1 mL per level)
• Injectate (diagnostic): 3 mL 2% lidocaine (1 mL per level)

Genicular Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

- Injectate: 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine (1 mL per site)

Greater Trochanteric Bursa Injection - Fluoroscopy

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Procedure:

- Lateral position with target hip up

- Take lateral images

- Injectate: 40 mg Depo-Medrol + 4 mL 0.5% lidocaine

- No contrast

Hip Injection Intra-articular - Fluoroscopy

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

- Supine position

- Injectate: 40 mg Depo-Medrol + 4 mL 0.5% lidocaine

- Yes contrast

- Lateral to medial trajectory

Hypogastric Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Omnipaque

Procedure:

• Injectate: 5 mL bupivacaine 0.25% + 5 mL lidocaine 5% + 40 mg Depo-Medrol
• Target at anterolateral surface of L5
• Confirmation with contrast

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Procedure:

• Injectate: 80 mg Depo-Medrol (2 mL) + 4 mL 0.5% lidocaine
• No preference in terms of LOR technique

Lumbar Medial Branch Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Enter needle coaxial ipsilateral oblique Scotty dog
  • Sometimes opts for AP if bilateral
• Injectate: 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine (1 mL per level unilateral) or 80 mg Depo-Medrol + 4-5 mLs of 0.25% bupivacaine (1 mL per level bilateral)

Lumbar Radiofrequency Ablation

Medications to order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL) - 1cc in each

Procedure:

• AP for SA needle then “Scotty dog” for L4 and L5 (co-axial)
  • Start with caudal tilt; “walk off” anteriorly after contacting bone
  • 18G needles

Piriformis

Medications to order:

Lidocaine 0.5% (50 mL)

Bupi 0.25%

Depo 40

Procedure:

• Fluoro
• Mix 2cc lido, 2cc bupi, 1cc depo
• Come in at the joint, retract, angle 45 degrees, readvance, inject

Shoulder Injection Intra-articular with Fluoro

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

- Supine position

- Injectate: 40 mg Depo-Medrol + 4 mL 0.5% lidocaine

- Yes contrast

Sacroiliac Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Dreyfuss (4 sites; 2 needles) + SI intra-articular joint injection
  • Needle 1 targets SA + S2; needle 2 targets S1 + S3 + intra-articular
• Injectate: 40 mg Depo-Medrol + 4 mL 0.25% bupivacaine (1 mL per site)

Suprascapular Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: 40 mg Depo-Medrol (1 mL) + 3 mL 0.5% lidocaine

Supraorbital Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Dexamethasone (1cc, 10mg/cc)

Procedure:

• Injectate: 5 dexamethasone plus even mix of lido/bupi per side, aim for 2cc per side

Transforaminal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg

Omnipaque

Procedure:

• Injectate (per level): 10 mg dexamethasone + 1 ml 0.5% lidocaine
• Yes contrast

Trigger Point Injections

Medications to Order:

0.5% lidocaine

+/-40 mg Depo-Medrol

Procedure:

- Injectate: lidocaine 0.5% +/- Depo-Medrol (10-20 mg total)

- usually does just lido

Lumbar Sympathetic Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate (per level): 80 mg Depo-Medrol + 7 mL bupivacaine 0.25% + 7 mL 0.5% lidocaine (total 15 mL injectate)
• Yes contrast
  • Inject in lateral view to visualize needle tip anterior to vertebral body

Occipital Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 80 mg

Procedure:

• Injectate (per site): 40 mg depo-medrol + 3 mL 0.5% lidocaine and 3 mL 0.25% bupivacaine to be divided between GON and LON (GON on each side - 2-3 mL and LON 1 mL)

Dr. Christopher Gilligan

- Does his own telehealth but prefers help with virtual visits

- For Hale - 1st floor Daniel Ponton Teaming Room

- Prefers lidocaine 1% for subcutaneous infiltration

- Label all syringes on tray

- Often takes images of local needle after skin infiltration to establish trajectory

Caudal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 80 mg

Omnipaque 300 mg

Procedure:

• Prone position with lateral fluoroscopy
• 25 gauge spinal or local needle
• Yes contrast
• Injectate: 80 mg methylprednisolone + 2 mL normal saline +1 mL lidocaine (5 mL total)

Cervical Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 80 mg

Omnipaque 300 mg

Procedure:

• LOR to 2 mL air + 2 mL normal saline
• Starts AP then goes lateral (no CLO)
  • Returns to AP for one additional shot after contrast
• Injectate: 80 mg methylprednisolone + 1 mL normal saline (3 mL total)

Cervical Radiofrequency Ablation

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Lidocaine 2% (5 mL)

Greater Trochanteric Bursa Injection with Fluoro

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% (10 mL)

Omnipaque 300 mg

Procedure:

- Lateral position target hip up

- Take lateral images

- Injectate: 40 mg Depo-Medrol + 1 mL 0.25% bupivacaine + 1 mL 0.5% lidocaine  

- Yes contrast

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 80 mg

Omnipaque 300 mg

Procedure:

• LOR to 2 mL air + 2 mL normal saline
• Starts AP then goes lateral (no CLO)
  • Returns to AP for one additional shot after contrast
• Injectate = 80 mg methylprednisolone + 1 mL 0.5% or 1% lidocaine (3 mL total)

Lumbar Radiofrequency Ablation

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Lidocaine 2% (5 mL)

Procedure:

• 22-gauge radiofrequency needle

Piriformis Injection (Fluoroscopy)

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 40 mg

Omnipaque 300 mg

Procedure:

• 25-gauge 2.5 inch needle
• Injectate: 2 mL of normal saline + 40 mg Depo-Medrol

Transforaminal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Dexamethasone 10 mg

Omnipaque 300

Procedure:

• Injectate: 10 mg dexamethasone + 1 ml 0.5% lidocaine
• Yes contrast

Trigger Point Injections

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Bupivacaine 0.25% 30 mL

Procedure:

• Injectate: lidocaine 0.5% + bupivacaine 0.25%
• No steroid (only for occipital nerve block)

Sacroiliac Joint Intra-articular Injection

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% 30 mL

Procedure:

- Injectate: 1 mL 0.5% lido + 1 mL 0.25% bupi + 40 Depo-Medrol (3 mL total)

Shoulder Intra-articular with Fluoro (AC joint)

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% 30 mL

Procedure:

- Supine position

- Injectate: 2 mL 0.5% lido + 2 mL 0.25% bupi + 40 mg Depo

Dr. Danielle Sarno

- Provides fellows with print-out of procedures including patient history and relevant imaging findings

- Sometimes prefers personal .DS smartphrases for procedure notes

- Include .name and .DOB on procedure notes

- Include pre-procedure and post-procedure diagnosis and pre-procedure and post-procedure pain scores (VAS)

- Prefers you monitor and help the patient out of the room post-procedure

Cervical Medial Branch Blocks

Medications to Order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL)

Procedure:

• Injectate: 0.5 mL lidocaine 2% (for diagnostic)
• Prone positioning
  • Needle insertion and target location identical to cervical RFL

Cervical Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Omnipaque

Dexamethasone

Procedure:

• Injectate: Dex 10mg
• Prone positioning
  • No higher than C6-C7

Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Injectate for lumbar: 2 mL 0.5% lidocaine + 2 mL (80 mg) methylprednisolone
• Injectate for cervical: 2 ml 0.9% NS + 1 mL (10 mg) dexamethasone
• Prefers continuous LOR technique (half saline and half air) with one hand driving needle and one hand on syringe
  • Careful confirmation with contrast in AP and CLO views
  • Attentive to epidural contrast pattern

Lumbar Medial Branch Block

Procedure

• Injectate (if for diagnostic only): 0.7 mL 0.25% bupi per level

Lumbar Radiofrequency Nerve Ablation

Medications  to Order:

Lidocaine 2% (5 mL)

Lidocaine 0.5% (50 mL)

Piriformis Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% (10 mL)

Omnipaque

Procedure:

• Injectate: 40 mg Depo-medrol + 1 mL 0.25% bupivacaine + 1 mL 0.5% lidocaine
• Confirmation with contrast (fluoroscopy)
• Needle insertion mid-point between posterior SIJ and greater trochanter

Sacroiliac Intra-articular Injection

Medications  to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol (40 mg)

Bupivacaine 0.25%

Procedure

• Injectate: 1 ml 0.25% bupi + 1 ml (40 mg) Depo + 1 ml 0.5% lido (3 mL total)
• Target inferior pole of sacroiliac joint (single injection)

Transforaminal Epidural Steroid Injection

Medications  to Order:

Dexamethasone (10 mg)

Lidocaine 0.5% (50 mL)

Procedure

• Injectate (per level): 10 dexamethasone (1 mL) + 1 ml 0.5% lido
  • Inject dexamethasone first then lidocaine
• Omnipaque for confirmation with tubing and pulsed live
• 22-gauge 3.5 inch for sacral TFESI and 5 inch for lumbar TFESI
  • No preference for bent vs. straight needle

Trigger Point Injections

Medications to Order:

Lidocaine 0.5% (50 mL)

Procedure:

• Injectate: lidocaine 0.5% only***? (unconfirmed)

Dr. David Janfaza

- Weekend call: meet ~ 7:30-8:00 AM (pre-rounding optional)

Checks in later in the day to run through pages

Stays in hospital until morning notes are completed

Cervical Medial Branch Blocks

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol

Bupivacaine 0.25% (10 mL)

Procedure:

• 25-gauge needle
• Injectate: 13 mg Depo-Medrol + 0.5 mL 0.25% bupivacaine
• Lateral positioning
  • Confirmation in lateral fluoroscopy

Genicular Nerve Block

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

60 mg Depo-Medrol

Procedure:

• Injectate: 4.5 mL 0.25% bupivacaine + 20 mg Depo-Medrol (5 mL) per level

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol mg

Procedure:

• Injectate: 80 mg Depo-medrol + 2 mL 0.5% lidocaine
• Contrast only in patients with insurance that requires
• Contralateral oblique and lateral

Lumbar Medial Branch Blocks

Medications to Order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 60 mg (unilateral)

Procedure:

• Injectate: 20 mg Depo-medrol + 0.5 mL 0.25% bupivacaine per level
• Slightly oblique

Occipital Nerve Block

Medications to Order:

Bupivacaine 0.25% (10 mL)

40 mg Depo-Medrol

Sacroiliac Joint Injection

Medications to Order:

Bupivacaine 0.25% (10 mL)

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Procedure:

• Injectate: 40 mg Depo-medrol + 1 mL 0.25% bupivacaine
• Intra-articular to inferior pole

Stellate Ganglion Block

Medications to Order:

Bupivacaine 0.25% (10 mL)

Lidocaine 0.5% (50 mL)

Trigger Point Injections

Medications to Order:

Bupivacaine 0.25% (10 mL)

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: 9 mL 0.25% bupivacaine + 40 mg Depo-Medrol

Dr. Alex Kim

- Prefers personal template .AKINITIAL for initial visits

- Writes his own procedure notes

- For Hale - 1st floor Daniel Ponton Teaming Room

Caudal Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Yes contrast
• 22-gauge spinal needle
• Injectate: 80 mg Depo-Medrol + 5-6 mL 0.5% lidocaine

Cervical Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Loss-of-resistance to 3 mL contrast syringe
• Injectate: 80 mg Depo-Medrol + 2 mL 0.5% lidocaine

Epidural Blood Patch

Medications to order:

Lidocaine 0.5% (50 mL)

Omnipaque

Procedure:

• Sterile IV amLess (apply large Tegaderm over inserted IV including extension port tubing)
• Target L5 and S1 interspace
• Injectate: minimum 20 mL blood (target as much as tolerated by patient)

Greater Trochanteric Bursa Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Procedure:

• Lateral with affected side up if unilateral
• Injectate: 40 mg Depo-Medrol + 4-5 mL 0.5% lidocaine

Iliopsoas Injection (Fluoroscopy)

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: ***

Lumbar Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg

Omnipaque

Procedure:

• Loss-of-resistance to 3 mL contrast syringe
• Contralateral oblique imaging
• Injectate: 80 mg Depo-Medrol + 3 ml 0.5% lidocaine

Lumbar Medial Branch Blocks

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg (unilateral) 80 mg (bilateral)

Omnipaque

Procedure:

• Injectate: 40 mg Depo-Medrol + 2 ml 0.25% bupivacaine (1 mL per level)

Lumbar Radiofrequency Ablation

Medications to order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL)

Procedure:

• AP for SA needle placement then “Scotty dog” for L4 and L5
  • “Walk off” anteriorly

Sacroiliac Joint Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg (per side)

0.25% bupivacaine 30 mL

Procedure:

• Intra-articular injection + sacral ala
• Injectate: Depo-Medrol 40 mg + 4 mL 0.25% bupivacaine
  • 3 mL of injectate intra-articular + 0.5 mL per-articular
  • Add 3.5 mL lidocaine to remaining 1.5 mL injectate and inject 4 mL at sacral ala

Shoulder Injection - Glenohumeral plus Subacromial Bursa

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 60 mg

Bupivacaine 0.25% (10 mL)

Omnipaque

Procedure:

• Injectate for GH: Depo-Medrol 40 mg + 3 mL 0.25% bupivacaine
• Injectate for bursa: Depo-Medrol 20 mg + 3.5 mL 0.25% bupivacaine
• For GH: land on humerus at 10-11 o’clock
  • Confirm with contrast
• For bursa: land on humerus at 12 o’clock, withdraw ~ 1 cm and advance cephalad
  • Confirm with contrast

Trigger Point Injections

Medications to order:

0.25% bupivacaine 30 mL

Depo-Medrol 40 mg

Procedure:

• Injectate: 9 mL 0.25% bupivacaine + 40 mg Depo-Medrol

Dr. Stephanie Regenhardt

- For procedure notes, prefers copy forward of prior notes and embed procedure note

Caudal Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg (2 mL)

Procedure:

• Lateral image
• 22 G 3.5 inch spinal needle
• Injectate: 2 ml 0.5% lidocaine + 2 mL normal saline + 80 mg Depo-Medrol

Genicular Nerve Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 80 mg (2 mL)

Lumbar Epidural Steroid Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 80 mg (2 mL)

Procedure:

• No preference with LOR style, but she does the yellow tuohy with LOR to contrast in 3cc syringe
• Confirmation of depth in CLO
• Injectate: 3 mL lidocaine 0.5% + 80 mg Depo-Medrol

Lumbar Medial Branch Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Procedure:

• Injectate: 40 mg Depo-Medrol + 2 mL 0.25% bupivacaine (1 mL per level)
  • In some cases, may do just bupi
• AP + oblique “Scotty Dog” views
• If bilateral, do bottom two first (S1) marked with needles. Then, oblique one side and do L4 and 5 simultaneously, then oblique the other side and do the other two

Lumbar Radiofrequency Ablation

Medications to order:

Lidocaine 0.5% (50 mL)

Lidocaine 2% (5 mL)

Occipital Nerve Block

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg

Sacroiliac Joint Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 80 mg (2 mL)

Procedure:

• Injectate: 40 mg Depo-Medrol + 1-2 mL 0.25% bupivacaine
• Infra-articular inferior pole

Trigger Point Injections

Medications to order:

Lidocaine 0.5%

Procedure:

• Injectate: 10 mL lidocaine (1 mL per site)
• Check notes, sometimes she does depo in old people who can’t get other procedures

Trochanteric Bursa Injection

Medications to order:

Lidocaine 0.5% (50 mL)

Bupivacaine 0.25% (10 mL)

Depo-Medrol 40 mg (1 mL)

Procedure:

• Supine
• Injectable: 40 mg Depo-Medrol + 2-3 mL 0.25% bupivacaine

Dr. Richard Gao

- For procedure notes, prefers copy forward of prior notes and embed procedure note

Lumbar Medial Branch Blocks

Medications to Order:

0.5% lidocaine (50 mL)

0.25% bupivacaine (10 mL)

Depo-Medrol 40 mg/mL (unilateral) vs. 80mg/mL (bilateral)

Procedure:

• 22 gauge 3.5 inch spinal needle (bent tip)
• Injectate: 1 mL at each level of mixture 2mL 0.25% bupivacaine + 1mL depo-medrol
• AP-only

Cervical Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Decadron 10mg/mL vial

Omnipaque 180

Procedure:

• Contralateral oblique view
• Loss of resistance with omnipaque in 3 cc syringe

Lumbar Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (80mg total)

Omnipaque 180

Procedure:

• 20g tuohy needle
• Advance in contralateral oblique view with loss of resistance to omnipaque in 3 cc syringe

• Inject mixture of 3ml 0.5% lidocaine, 2ml 40mg/mL depo-medrol or 4ml 0.5% lido and 1ml 80mg/ml depo

Lumbar Radiofrequency Ablation:  

Medications to Order:

Lidocaine 0.5% (50 mL)  

Lidocaine 2% (5 mL)  

Procedure:

• 18g radiofrequency needle

• Complete sensory and motor testing
• Inject each level with 1ml 2% lidocaine prior to RFA

Lumbar Transforaminal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg (occasionally 20 mg for 2 level)

Procedure:

• Pointer initially in AP at lateral inferior edge of transverse process

• Transition from AP to oblique with pointer in place
• Bent 22-gauge 3.5/5 inch spinal needle
• Injectate: 5-10 mg dexamethasone + 1-1.5 mL 0.5% lidocaine per level

Trigger Point Injections

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (1 mL vial) (occasionally)

Procedure:

• Ask if lidocaine-only (usually first TPIs) or lidocaine + steroid

• Injectate: 1 mL Depo-Medrol 40 mg/mL + Lidocaine 0.5% (50 mL)

Sacroiliac Joint Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• Medial to lateral approach (intra-articular)
• #22-gauge 3-½ inch spinal needles (inferior pole)

• 40 mg Depo-Medrol and 3 mL 0.25% bupivacaine into each joint

Cervical Medial Branch Block

Medications to order:

Lidocaine 0.5% (50 mL)

Dexamethasone 10 mg/mL

Bupivacaine 0.25% (10 mL)

Procedure:

• Patient lateral

• Injectate (for 3 levels): 1ml of a 3ml mix of 10 mg dexamethasone + 2 mL 0.25% bupivacaine
• 3.5 inch 22-gauge spinal needle with bent tip (only 1 needle and re-direct)

Caudal Epidural Steroid Injection

Medications to Order:

Lidocaine 0.5% (50 mL)

Omnipaque 180

Depo-Medrol 40 mg/mL

Procedure:

• #22 gauge spinal needle

• Inserts midline  
• Confirmation with contrast in lateral + AP views  

• Inject 80 mg methylprednisolone with 6 mL 0.5% lidocaine

Baclofen Single Shot (with Fluoroscopy)

Medications to Order:

Baclofen 50 to 75 mcg/ml  

Confirm dose with attending

Procedure:

• Spinal kit with 25 G Whitacre

Genicular Nerve Block:  

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate: 40 mg Depo-Medrol + 8 mL 0.25% bupi; 3 ml at each of the 3 levels (per knee)

Knee Intra-Articular Steroid

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL (5 mL vial)

Bupivacaine 0.25% (10 mL)

Procedure:

• #22 spinal needle
• Injectate: 6 mL 0.25% bupivacaine + 80 mg Depo-Medrol
• Fluoroscopy with 3.5 inch spinal needle

Shoulder Injection with Fluoroscopy

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL  

Bupivacaine 0.25% (10 mL)

Procedure (Glenohumeral):

• Lateral to medial approach  
• #22-gauge 3-½ inch spinal needle
• Injectate: 40 mg Depo-medrol + 5 mL 0.25% bupivacaine  

Procedure (Acromioclavicular):

• #25-gauge 1-½ inch local needle
• Injectate: 40 mg Depo-medrol + 1 mL 0.25% bupivacaine  

Sphenopalatine Ganglion Block

Medications to Order:

Bupivacaine 0.5%  

Procedure:

• Cotton swab  

TAP Block (Ultrasound)

Medications to Order:

Lidocaine 0.5% (50 mL)

Depo-Medrol 40 mg/mL

Bupivacaine 0.25% (10 mL)

Procedure:

• Injectate: 9 mL 0.25% bupivacaine + 40 mg Depo-Medrol (per side)
• Needle insertion (Pajunk) from medial to lateral

Suprascapular Nerve Block

Medications to Order:

Depo-Medrol 40 mg/1mL vial

Bupivacaine 0.25% (10 mL)

Lidocaine 0.5%

Procedure:

• 25g 3.5 inch spinal needle
• Ipsilateral oblique view with cephalad tilt to target suprascapular notch; confirm depth with lateral view
• Inject mixture of 1cc depo-medrol with 3cc bupivacaine
  

Dr. Arti Ori

Occipital Nerve Block

Medications to order:

Bupi 0.5% (10 mL if bilateral)

Depo-Medrol 40 mg

Procedure: 3cc to greater, 2cc to lesser, can draw all up in one syringe with 25g needle

Cervical Medial Branch Blocks

Medications to Order:

***Lidocaine 0.5% (50 mL)

***Lidocaine 2% (5 mL)

***

Knee Intra-Articular Steroid with Fluoroscopy

Medications to Order:

Lidocaine 0.5% (50 mL) > draw up 10cc

Bupivacaine 0.25% (10 mL) > draw up 5 cc per side

40 mg Depo-Medrol mixed in bupi

Find divet under kneecap (lateral/caudal) and inject lido all the way to the end of the needle. Shot, see where it is, try to get it in the center of the joint.

Sacroiliac Joint Intra-articular Injection

Medications to Order:

Lidocaine 0.5% (50 mL) or 1% (30 mL)

Depo-Medrol 40 mg

Bupivacaine 0.25% 30 mL

Procedure:

- Injectate: 3 mL 0.25% bupi + 40 Depo-Medrol (3 mL total)

Oblique 20 deg contralateral to the side, hold finder needle just above gluteal cleft and a bit lateral.

Trigger Point Injections

Medications to order:

Lidocaine 0.5%

Procedure:

• Injectate: 10 mL lidocaine (1 mL per site)

GTB (Greater trochanteric bursa):

• Coming in laterally at greater trochanter
• Lido in 10cc
• 40 depo + 3 of 0.25 bupi in 5cc

Genicular nerve block Injections

• 3 sites, superomedial, inferomedial, superolateral, landing on bone at each site
• Insert needles in AP but take a lateral image before injection
• Draw up 10cc bupi with 40 depo, do 3cc at each sites

Dr. Reilly

For synvisc, aspirate joint fluid before injecting