How are transforaminal epidural corticosteroid injections administered for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

The 22-gauge, 3.5-inch needle is walked off this bony landmark after it is withdrawn and then directed inferiorly. An AP fluoroscopic view is used to verify that the needle is not directed too far medially from the 6 o’clock mark on the pedicle, thereby avoiding a deep placement with its risk of entry into the dural sleeve or spinal canal. Correct needle placement is next verified by a lateral view with injection of 0.2-0.4 mL of a suitable contrast medium.

Contrast flow should flow proximally around the pedicle into the epidural space. Injections should be immediately stopped if a patient complains of pain upon injection. If epidural placement and satisfactory flow of contrast is observed, then 6 mg of betamethasone/solution or 20-40 mg of methylprednisolone or triamcinolone suspension with 0.5-2 mL of 2-4% preservative-free lidocaine or 0.5-0.75% bupivacaine is slowly injected in a total volume of 1-3 mL. Transient mild pressure and paresthesia are commonly noted.

Any bleeding tendencies, especially anticoagulation or coagulopathy, represent absolute contraindications for lumbar epidural spinal injections. Any evidence of local or systemic infection should call to question the relative need versus risk of the procedure due to the potential for hematogenous spread via the Batson plexus. Although infrequent, unintentional dural puncture occurs slightly more often using the transforaminal approach. This complication must be immediately recognized to prevent tragic consequences due to total spinal anesthesia, loss of consciousness, hypotension, and apnea. Complications seen with this approach at other anatomic levels have already been outlined at length. [19]


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