In Defense of the Meticulous: A Case Against Ambiguity, and a Time to Standardize.

precise pathology, the one devoted to target specificity, is discounted by many who maintain that such idealism is misplaced and does not influence outcomes. We would like to commend the authors of the article on anatomical flow patterns in the lumbar epidural space for providing further evidence that target access is critical for success (1). The authors have once again shown that parasagittal interlaminar epidural steroid injections are more likely to place the injectate into the ventral epidural space (1-3). The logic and the evidence are aligned. What is even more striking in these studies is the correlation of clinical success rate with the rate of ventral epidural access by the injectate (1,3). In contrast, the problem of imprecision was demonstrated by the New England Journal of Medicine study on spinal stenosis that compared outcomes for epidural steroid plus local anesthetic to those for local anesthetic only. Target identification and access became subservient to routine practice. Construct validity was lost. No differences were to be expected. No differences could be found (4). Of course, a study rooted in precision could arrive at the same results; those results would however be more translational. A parasagittal approach merely implies anything off the mid-sagittal plane. Indeed, only a closer scrutiny of these articles reveals that the needle was in fact placed in the most lateral section of the interlaminar opening. A busy practitioner may Brief Commentary