Lumbar Transforaminal Epidural Steroid Injection

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Pre-Procedure0/2

Perform time-out: verify patient identity, procedure, level, laterality, allergies, and anticoagulation status.

Confirm no contrast allergy. If allergic, pre-medicate with steroids and antihistamines per ACR protocol. NEVER use gadolinium as an epidural contrast alternative — intrathecal/epidural gadolinium is neurotoxic and can cause encephalopathy, seizures, and death.

ASIPP and SIS guidelines mandate a standardized time-out for all interventional spine procedures. Verify coagulation labs if on anticoagulants per ASRA guidelines.

Review imaging (MRI/CT) and confirm target level correlates with clinical presentation.

Misidentification of the target level is a leading cause of wrong-level procedures.

Compare axial MRI cuts at the disc level with the patient's radicular symptoms. The exiting nerve root at a given foramen corresponds to the level above the disc (e.g., L4 nerve exits above the L4-5 disc).

Setup0/3

Position patient prone on the fluoroscopy table with a pillow under the abdomen to reduce lumbar lordosis.

Ensure patient can communicate throughout the procedure. Monitor oxygen saturation.

Flattening the lordosis opens the neuroforamina and improves fluoroscopic visualization of the subpedicular space.

Set up C-arm in AP view. Adjust cranial-caudal tilt until the target endplates are squared and the spinous process is midline.

Minimize radiation exposure: collimate the beam and use intermittent fluoroscopy.

Squaring the endplates eliminates parallax error. The 'scotty dog' view is achieved with ~15-25 degrees of ipsilateral oblique rotation.

Select a 22-gauge or 25-gauge, 3.5-inch spinal needle. Prepare extension tubing with contrast syringe.

Use non-particulate steroid (dexamethasone) for all transforaminal approaches due to particulate embolization risk.

Particulate steroids (triamcinolone, methylprednisolone) carry risk of arterial embolization causing paraplegia or cerebellar infarct via the radiculomedullary artery.

Procedure0/5

Obtain ipsilateral oblique view (~15-25 degrees) to visualize the 'scotty dog.' Target the 6 o'clock position of the pedicle (subpedicular safe triangle).

Stay inferior and lateral to the pedicle. Never advance medial to the 6 o'clock position of the pedicle in oblique view.

The safe triangle is bordered superiorly by the pedicle, laterally by the exiting nerve root, and medially by the vertebral body. The target is the inferolateral aspect of the pedicle.

Advance the needle under intermittent fluoroscopy using a coaxial (gun-barrel) technique toward the subpedicular target.

If the patient reports radicular pain or paresthesias, stop and redirect the needle laterally.

Coaxial technique aligns the needle trajectory with the fluoroscopic beam so the needle appears as a dot. This ensures accurate trajectory to the target.

Confirm needle depth in lateral view: the needle tip should be in the posterior foramen, not past the mid-pedicular line.

Do not advance past the posterior vertebral body line to avoid dural puncture or cord injury.

In the lateral view, the posterior foramen corresponds to the space between the posterior vertebral body line and the anterior foramen. The ventral epidural space is the ultimate target.

Inject 0.5-1 mL of contrast under live fluoroscopy. Confirm epidural spread pattern with nerve root outline.

Use real-time (live) fluoroscopy during contrast injection to detect intravascular uptake immediately. If vascular flow is seen, reposition needle.

Proper epidural spread shows contrast outlining the nerve root sleeve and spreading into the ventral epidural space. Vascular uptake appears as rapid washout without epidural pattern.

Inject injectate: typically 1 mL dexamethasone (10 mg/mL) plus 0.5-1 mL preservative-free normal saline or local anesthetic.

Inject slowly. Stop if resistance is high (may indicate intraneural placement) or patient reports severe pain.

Total injectate volume is typically 1.5-2 mL for transforaminal approach to maintain selectivity. Higher volumes reduce diagnostic specificity.

Post-Procedure0/2

Remove needle and apply bandage. Transfer patient to recovery and monitor for 20-30 minutes.

Assess for new neurological deficits, hypotension, or allergic reaction before discharge.

Post-procedure monitoring allows detection of rare complications: epidural hematoma (progressive weakness), dural puncture headache, or vasovagal syncope.

Document procedure details: levels treated, needle gauge, contrast pattern, injectate composition and volume, and any complications.

Document fluoroscopy time and any intravascular uptake or needle repositioning events.

Thorough documentation supports medical-legal protection and enables outcome tracking for future treatment decisions.