CABINET TESLA  —  MEDICAL IMAGING CENTER

Cognac Clinic  •  Dr Pierrick MORALES

CT-GUIDED INFILTRATION QUESTIONNAIRE
71, Avenue d'Angoulème – 16100 Chateaubernard – COGNAC
Tel. : 05.45.35.68.91  •  Fax : 05.45.82.56.40  •  secretaire@radiologie-cognac.com  •  Website: https://www.radiologiecognac.com
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📋 Patient information

* Required: at least one 10-digit phone number and a valid email address.

⚠️ Please read each question carefully and correct if needed.

♀ For women only
A
Are you pregnant or could you be pregnant?
B
Are you breastfeeding?
🩸 Bleeding risk screening
1
Do you have any particular risk of bleeding?
2
Do you have a blood disorder or frequent/prolonged bleeding (e.g. nosebleeds)?
3
Are you taking a blood-thinning medication?
Anticoagulant or antiplatelet agent such as PLAVIX, ASPIRIN, WARFARIN, RIVAROXABAN…
⚠️ In most cases, this medication must be stopped before the procedure. We will tell you how far in advance.
⚕️ Allergy screening
4
Are you allergic to any medications?
5
Do you have asthma?
📄 Information note — Spinal corticosteroid infiltration

Your doctor has proposed a CT-guided foraminal corticosteroid injection. This notice informs you about the procedure, its benefits and its risks.

What does the procedure involve?

An anti-inflammatory corticosteroid is injected directly at the nerve responsible for the pain, where it exits the spinal column (the foramen between two vertebrae), under CT guidance.

Procedure details

You will be positioned lying face down on the CT table. After skin disinfection and local anaesthesia, the physician positions the needle to the nerve root. A small amount of iodinated contrast confirms the position, then the medication is injected.

⚠️ Risks and complications

As with any invasive procedure, there is a risk of infection (all necessary precautions are taken). There is also a very small risk of paraplegia, estimated at around 1 case in 8,000, caused by spinal cord ischaemia.

After the infiltration

Lying down and resting on the day itself and, if possible, the following day is advised. Improvement usually appears 48 hours after the infiltration.

If you develop a fever or severe pain in the following days, contact your doctor or our team immediately on 05 45 82 08 80.

📋 What to bring on the day of the procedure
① Your doctor's referral ② The requested laboratory test results ③ Your imaging records (X-rays, CT scans, MRI…) ④ The list of your current medications

Please come with someone if you can. There is no need to fast.

✅ Acknowledgement and informed consent
✍️ Patient declaration

I have personally completed this form, read the information leaflet, and give my informed consent for the spinal infiltration to be performed.

Signature :

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