PAIN MANAGEMENT SERVICE LINE

THE ESSENTIALS OF PAIN MANAGEMENT PROCEDURES

Brought to you by:
Procedural Education Committee of the Pain Management Service Line- Resident and
Fellow Section, Society of Interventional Radiology
For comments or suggested edits, please email SIRSurvivalGuide@gmail.com

AUTHORS:

Nicholson Chadwick, MD,

PGY-4, Virginia
Commonwealth University

EDITORS:

Hemant Kalia, MD, MPH,

Interventional Pain Management
Specialist, Rochester Regional
Health System
Joseph DeMarco, DO, SIR-RFS
Clinical Education Survival
Guide Liaison

LUMBAR EPIDURAL STEROID INJECTION

INDICATIONS
1. Radicular pain, with or without back pain secondary to spinal stenosis, degenerative
disease, or herniated disc.
A. Lumbar/interlaminar approach (ILESI)
B. Caudal approach
C. Transforaminal approach (TFESI): proven particularly successful in patients with
unilateral radicular symptoms associated with herniated nucleus pulposus
CONTRAINDICATIONS
1. Bleeding diathesis
2. Infection (local or systemic)
3. Pertinent drug allergy
4. Cauda equina syndrome
5. Pilonidal cysts
6. Pregnancy
PREOPERATIVE PREPARATION
1. Anticoagulants:
A. Periprocedural aspirin and NSAIDs may be continued due to no significant
increased risk of epidural hematoma.
B. Warfarin is withheld 4-5 days prior to injection with an INR > 1.5 as a
contraindication.
C. Prophylactic LMWH held 12 hours prior to procedure. Therapeutic LMWH
held for 24 hours.
D. Thienopyridine derivatives (eg clopidogrel) discontinued at least 7-10 days
before procedure.
2. Steroids can lead to increased blood glucose levels and the retention of water; thus, extra
caution and potential dose reduction should be considered in those with diabetes mellitus
and congestive heart failure.
3. Review of previous cross-sectional imaging and past surgical history.
CONSENT
1. Discuss risk of:
A. Bleeding
B. Infection
C. Transient nerve block and/or paralysis
D. Potential for conscious sedation
E. Allergic reaction
F. Worsening of pain or no pain relief.
PROCEDURE
1. Patient lies prone with bolster under abdomen to splay spinous processes.
A. If significant interspinous ligamentous calcification or articulation of spinous
processes (Baastrups disease) is present, then a paramedian approach may be
required to course the needle into the epidural space.
2. ILESI:
A. Obtain a true AP view centering the spinous processes. Mark intended site of entry
using radio-opaque instrument and sterile marker.
1. Typical site of entry overlies the superior portion of the more inferior spinous
process.
B. An alternate method is orienting the fluoroscope parallel to the inferior aspect of the
more superior spinous process, maximizing the interspinous space.
1. A site is marked just cranial to the more inferior spinous process.
C. If there is inadequate interspinous space, a paramedian approach can be useful. The
fluoroscope is rotated approximately 10 paramedian which profiles an alternate
trajectory towards the inferior border of the more superior lamina.
2

3.

4.
5.
6.

7.

8.

9.

TFESI:
A. The goal of needle placement is within the safe triangle or a
subpedicle/intraforaminal/supraneural location.
B. To obtain the scotty dog appearance of the pedicle en fos, oblique the fluoroscope
25-30.
C. The desired location is at 6 oclock on the pedicle, just below at the antero-infero- tip
of the scotty dogs snout.
Standard sterile preparation and drape procedures. Administer local anesthesia.
Under fluoroscopic guidance, spinal needle is advanced with slight cranial angulation to
guide the needle into the region with the largest amount of epidural fat.
ILESI:
A. The lateral view is used to determine the anatomic location of the ligamentum
flavum, which coincides with the posterior margin of the inferior articular process.
B. Check AP position to ensure midline trajectory (within the cortical margins of the
spinous processes).
C. The needle is advanced in 1mm increments with intervening checks utilizing the air
release technique. If the needle tip is within the ligamentum flavum, the syringe
plunger will retract. Once the needle tip enters the posterior epidural space, air will
freely inject without resistance or rebound of the plunger.
D. Alternate techniques use a syringe filled with saline. The needle is slowly advanced
while applying continuous pressure on the syringe plunger until loss of resistance is
felt.
TFESI:
A. Direct the needle using the oblique approach just inferior to the pedicle.
B. Once significant purchase is obtained, further advancement may be done in the AP
and lateral projections. A palpable pop is usually felt as the neuroforamen is pierced.
Inject water soluble non-ionic contrast through the needle via tubing and document proper
placement with spot images.
A. ILESI: In the lateral position, contrast should flow away from the needle along the
epidural space.
B. TFESI: Document contrast outlining the desired nerve root with reflux of contrast
back into the epidural space.
C. Once appropriate location is confirmed, administer injectate over 1-2 min under
intermittent visualization. Document dilution of contrast.
Remove needle, clean skin, and apply bandage.

POST-OPERATIVE CARE
1. Patients must be driven home.
2. Resume normal activities day after procedure.
3. Effects of anesthetic agent weans over the first few hours post injection.
4. Corticosteroid effect is not expected for 2-6 days. This can produce a bimodal pattern of
pain relief.
5. Pain relief can be expected to last from 6-8 weeks; however, some patients may experience
no relief of symptoms.
COMPLICATIONS
1. Dural puncture: postural headache (0.5-1%). Bed rest 24-28 hours and hydration. For
persistent headache, epidural blood patch may be performed.
2. Retrolaminar injection.
3. Intrathecal injection with potential for inadvertent spinal block, arachnoiditis, meningitis.
4. Paralysis: hypothesized to be secondary to intra-arterial injection of particulate
corticosteroids with subsequent embolization of spinal arteries. Overall, intravascular
uptake of injectate- 1.9%.
5. Infection: epidural abscess (0.1-0.01%).
6. Bleeding: epidural hematoma (0.01- 0.001%).
7. Transient increase in back pain.
8. Facial flushing, nausea, insomnia secondary to steroid injection.

FOLLOW UP
1. No follow up labs or imaging necessary.
REFERENCES
1.

Benyamin RM, Manchikanti L, Parr AT, et al. The effectiveness of Lumbar interlaminar epidural
injections in managing chronic low back and extremity pain. Pain Physician. 2012; 15: E363-E404.

2.

Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving
antithrombotic or thrombolytic therapy. Regional Anesthesia and Pain Medicine. 2010; 35: 64-101.

3.

Kennedy DJ, Plastaras C, Casey E, et al. Comparative effectiveness of lumbar transforaminal epidural
steroid injections with particulate versus nonparticulate corticosteroids for lumbar radicular pain due
to intervertebral disc herniation: a prospective, randomized, double-blind trial. Pain Medicine. 2014;
15: 548-555.

4.

Peterson BD, Davis KW, Choi J. Chapter 7: Epidural Steroid Injection. In: Ray CE, Pain management
in interventional radiology. New York, NY: Cambridge university press, 2008.

5.

Rosas H, Lee KS. Performing fluoroscopically guided interlaminar lumbar epidural injections. AJR.
2012; 199: musculoskeletal imaging video article.

6.

Schaufele M, Hatch L, Jones W. Interlaminar versus transformainal epidural injections for the
treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician. 2006; 9: 361-366.

7.

Ackerman W, Mahmood A. The efficacy of lumbar epidural steroid injections in patients with lumbar
disc herniations. Anesthesia and Analgesia. 2007; 104: 1217-1222.