Epidural Steroid Injection for Lumbosacral Radiculopathy

ow back pain combined with radicular pain remains as one of the most challenging musculoskeletal problems for its therapeutic management (1). This malady results from nerve root impingement and/or inflammation that causes neurologic symptoms in the distribution of the affected nerve root(s). Conservative treatment, percutaneous spine interventions and surgery have all been used as treatments; and the particular treatment that's chosen depends on the severity of the clinical and neurologic presentation. In 1930, Evans reported that sciatica could be treated by epidural injection. The use of epidural corticosteroid injections for the treatment of axial and radicular back pain was first reported in 1953 (2). Epidural steroid injections are currently used by many medical professionals for the treatment of lumbosacral radiculopathy. Performing " blind " epidural steroid injection lacks target specificity that often results in incorrect delivery of medication to the lesion. Imaging-guided steroid injections are now becoming more popular despite the controversy regarding their efficacy. Many reports, including a few randomized controlled trials, have documented the clinical utility of epidural steroid injections. There has been confusion in the literature regarding the terminology of a 'proper' epidural steroid injection (2). The term transforaminal epidural injection has been incorrectly referred to as selective epidural injections, selective nerve root blocks or nerve root sleeve injections. Additionally, the interlaminar epidural injections have been referred to the translaminar epidural injections. In our review of the MEDLINE literature, most of the articles entitled epidural steroid injection were concerned with the interlaminar approach. Gajraj (3) recommended that this therapeutic procedure be referred to a transforaminal epidural injection and the diagnostic procedure should be referred to as selective spinal nerve block. The International Spinal Injection Society (ISIS) recommends the utilization of the nomenclature based on the precise anatomic descriptors, i.e., transforaminal and interlaminar for the description of epidural injections. The epidural space has been accessed inferiorly through the caudal approach or posteriorly through the interlami-nar approach, and often without employing fluoroscopy. The transforaminal technique described by Derby et al. (4) involves positioning of a needle without pain provocation. Both the interlaminar and caudal epidural injections require relatively large volumes of the injectants for delivering steroids to the target site. This has the risk of an extra-epidural and intravascular needle placement. A transforaminal epidural steroid injection (TFESI) using a small volume of local anesthetic will anesthetize the spinal nerve and also partially anesthetize the dura, the posterior longitudinal ligament, …