Epidural Steroid Injection

Epidural Steroid Injection

Donald V. La Barge, III, MD

Sagittal T1WI MR shows severe central canal stenosis image at each disc level due to disc bulge/osteophyte and posterior ligamentous laxity. Note the epidural fat image at levels above surgery.

Axial T2WI MR shows severe central canal stenosis image due to circumferential disc bulge and marked facet joint hypertrophic changes image. Ligamentous laxity is again evident image.



  • Epidural steroid injection (ESI)


  • Corticosteroid/anesthetic injection into lumbar epidural space via interlaminar or transforaminal approach



  • Lumbar radiculopathy

    • Degenerative disc disease

    • Post-traumatic

  • Residual pain following vertebroplasty/kyphoplasty


  • Coagulopathy

  • Allergy to injectate

  • Local or systemic infection

  • Relative contraindications

    • Iodinated contrast allergy, pregnancy, active hepatitis

Getting Started

  • Things to check

    • Appropriate procedure

      • Clinical examination consistent

      • Prior imaging: Adequate epidural space; causative lesion

        • Note that epidural space may be absent (due to scarring) in postoperative back

    • Laboratory data

      • Coagulation studies as indicated for patients undergoing anticoagulation therapy

        • Prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR), platelet count

      • Markers of infection/inflammation

    • Informed consent

  • Medications

    • Local anesthetic

    • Long-acting anesthetic for injectate

    • Corticosteroid

  • Equipment list

    • Radiopaque marker

    • Sterile prep and drape materials

    • Interlaminar ESI

      • Glass syringe with preservative-free saline (“loss of resistance” technique)

      • 18-22-gauge Tuohy needle

    • Transforaminal ESI

      • 22-gauge spinal needle

    • Caudal ESI

      • 18-22-gauge Tuohy needle

      • In patients requiring higher lumbar level injections via caudal approach, consider 4F hydrophilic catheter or vascular sheath and 0.035 wire

    • Needle and syringe for local anesthetic

    • Syringe for injectate

    • Syringe for contrast material with extension tubing


Patient Position/Location

  • Best procedure approach

    • Prone

Equipment Preparation

  • Draw ˜ 5 mL local anesthetic

  • Draw ˜ 5 mL iodinated contrast if no allergy, and preload extension tubing

  • Draw corticosteroid and anesthetic injectate

    • Dilution in 2 mL preservative-free saline decreases viscosity and may facilitate diffusion of injectate within epidural space

  • Draw ˜ 3-5 mL preservative-free saline into glass syringe if using “loss of resistance” technique

Procedure Steps

  • Procedure “time out”

    • Confirm correct patient, level of puncture, and procedure to be performed

  • Mark appropriate level under fluoroscopy or CT guidance

  • Perform sterile prep and drape

  • Create skin wheal, and anesthetize subcutaneous tissue

  • Insert procedure needle into subcutaneous tissue

  • Carefully advance under intermittent imaging guidance into epidural space

  • Interlaminar

    • Target superior lamina near midline

    • Carefully “walk” off lamina superiorly, then attach glass syringe

    • Very carefully advance needle until loss of resistance occurs with glass syringe plunging

  • Transforaminal

    • Target superomedial neural foramen

    • Slowly advance adjacent to exiting nerve root

  • Caudal

    • Sacral hiatus/canal

    • Advance Tuohy needle through canal to epidural space using “loss of resistance” technique

      • If contrast does not opacify high enough into lumbar canal, consider use of catheter or vascular sheath

        • Exchange needle over 0.035 wire, and navigate sheath or catheter over wire to desired level under fluoroscopic guidance

  • Attach contrast tubing, and slowly inject contrast, if not contraindicated, to verify needle placement

  • Document needle placement with imaging

  • Attach injectate, and slowly inject

  • Remove needle, and achieve hemostasis

  • Apply bandage

Findings and Reporting

  • Document pain before and after procedure

  • Document correct level

Alternative Procedures/Therapies

  • Radiologic

    • Selective nerve root block

  • Surgical

    • Decompression

  • Other

    • Rhizotomy

    • Radiofrequency ablation


Expected Outcome

  • Reproduction of pain with needle placement/injection

  • Improvement in pain after injection

Things to Do

  • Assess patient before and after procedure for pain and other neurologic symptoms

Things to Avoid

  • Interlaminar approach without identifiable epidural space on pre-procedure imaging

    • Often obliterated in postoperative back



  • Incorrect level injected/failure of pain relief

  • Vasovagal reaction


  • Most feared complication(s)

    • Intravascular injection

      • Spinal cord ischemia

    • Spinal cord puncture

  • Other complications

    • Infection

    • Bleeding

    • Nerve injury


1. Peterson C et al: Evidence-based radiology (part 1): Is there sufficient research to support the use of therapeutic injections for the spine and sacroiliac joints? Skeletal Radiol. 39(1):5-9, 2010

2. Wybier M et al: Paraplegia complicating selective steroid injections of the lumbar spine. Report of five cases and review of the literature. Eur Radiol. 20(1):181-9, 2010

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Sep 22, 2016 | Posted by in EMERGENCY RADIOLOGY | Comments Off on Epidural Steroid Injection
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