Transforaminal Epidural Steroid: Evidenced Low back pain intervention

by Dr. Raghavendra Ramanjulu


Low back pain (LBP) is the most common pain condition warranting for a physician visit(1). The general prevalence among the Indian population being as high as 57 to 85%(2) (3). The causative factors ranging from the nonspecific myofascial pains to the commoner feared disc pathology. The typical pain symptoms described of disc pathology would be as low back pain with radiating pain to the lower limbs. The additional descriptive could be numbness and tingling in the lower limbs. The specific descriptive of weakness in lower limb or loss of bowel and bladder control are deemed red flags and should be surgically intervened at the earliest. The majority of the LBP patients would improve with just conservative interdisciplinary management, individualised physiotherapy and ergonomic interventions in 3months. The group of LBP patients who would persist to have pain even beyond 3 months of active conservative management would be suitable for a Transforaminal epidural steroid.

The Interlaminar steroid injection

Placing the needle in the posterior interspinous are nd entering the epidural space, with the drug being injected into a wider area posteriorly.

Transforaminal steroid injection

Often referred to as selective root intervention, involves needle placement in close proximity to the exiting nerve root, and the medication travels along the nerve sleeve.


  • Disc Tear
  • Foraminal stenosis
  • Lateral disc herniations or recess stenosis
  • Post-surgery with pain recurrence

long-term (6 months to year) success rates for transforaminal epidural glucocorticoid injections ranged from 71% to 84%(4). The transforaminal epidural is better in comparison to the interlaminar epidural steroid due to following factors and well evidenced(5).

  • Drug deposition closer to the site of pathology
  • Smaller needle thickness used (Spinal Needle 23g) in comparison
  • Specific to certain root value could be of diagnostic value
  • Its Precise (Fluoroscopy guided) and specific (verified by dye spread)


Oblique View - Patient Prone and post squaring of vertebral body and spinal needle in the foramen.

Lateral View - Patient Prone and post squaring of vertebral body and Sub pedicular placed spinal needle in the mid -foramen.

AP View - Needle at L4-5 Sub-pedicular, spinal needle in the foramen with dye spread along the nerve sleeve


The multiple evidence reviewed indicate that transforaminal injections are generally safe. Most of the studies reported no complications(6) (7).


Lumbar transforaminal epidural injections have strong evidence (Level 1) indicating their use for LBP with radicular lower limb pain(5)


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