Cervical Transforaminal Epidural Steroid Injections Research Articles

The effectiveness of cervical transforaminal epidural steroid injections for the treatment of cervical radicular pain: A prospective cohort study reporting 12-month outcomes

The effectiveness of cervical transforaminal epidural steroid injections for the treatment of cervical radicular pain: A prospective cohort study reporting 12-month outcomes

Deep Learning Algorithm Trained on Oblique Cervical Radiographs to Predict Outcomes of Transforaminal Epidural Steroid Injection for Pain from Cervical Foraminal Stenosis.

We developed a convolutional neural network (CNN) model to predict treatment outcomes of transforaminal epidural steroid injection (TFESI) for controlling cervical radicular pain due to cervical foraminal stenosis. We retrospectively recruited 293 patients with cervical TFESI due to cervical radicular pain caused by cervical foraminal stenosis. We obtained a single oblique cervical radiograph from each patient. We cut each oblique cervical radiograph image into a square shape, including the foramen that was targeted for TFESI, the intervertebral disc, the facet joint of the corresponding level with the targeted foramen, and the pedicles of the vertebral bodies just above and below the targeted foramen. Therefore, images including the targeted foramen and structures around the targeted foramen were used as input data. A favorable outcome was defined as a ≥ 50% reduction in the numeric rating scale (NRS) score at 2months post TFESI compared to the pretreatment NRS score. A poor outcome was defined as a < 50% reduction in the NRS score at 2months post TFESI vs. the pretreatment score. The area under the curve of our developed model for predicting the treatment outcome of cervical TFESI in patients with cervical foraminal stenosis was 0.823. A CNN model trained using oblique cervical radiographs can be helpful in predicting treatment outcomes after cervical TFESI in patients with cervical foraminal stenosis. If the predictive accuracy is increased, we believe that the deep learning model using cervical radiographs as input data can be easily and widely used in clinics or hospitals.

The effectiveness of cervical transforaminal epidural steroid injections for the treatment of cervical radicular pain: A prospective cohort study reporting 12-month outcomes

ObjectivesTo evaluate the effectiveness of cervical transforaminal epidural steroid injection (CTFESI) for the treatment of unilateral cervical radicular pain. DesignSingle-group prospective cohort study. MethodsOutcomes included ≥50% reductions in Numeric Rating Scale (NRS) for arm pain, ≥30% Neck Disability Index (NDI-5) improvement, health-related quality of life (EQ-5D), global improvement (PGIC), personal goal achievement (COMBI), Chronic Pain Sleep Index (CPSI), and healthcare utilization at one, three, six, and 12 months. Data analysis included descriptive statistics with the calculations of 95% confidence intervals (CIs), contingency table analysis, and multilevel logistic regression (LR) analysis, including a worst-case (WC) sensitivity analysis in which missing data were treated as treatment failure. Participants who were treated surgically were considered failures in the categorical analyses. Results33 consecutively enrolled participants (63.6% females, 51.2 ± 12.2 years of age, BMI 28.3 ± 4.5 kg/m2) were analyzed. Success rates for ≥50% reduction in NRS for arm pain at one, three, six and 12 months were 57.6% (95% CI 40.8–72.8%), 71.9% (95% CI 54.6–84.4%), 64.5% (95% CI 46.9–78.9%), and 64.5% (95% CI 46.9–78.9%). Success rates for ≥30% improvement in NDI-5 were 60.6% (95% CI 43.7–75.3%), 68.8% (95% CI 51.4–82.0%), 61.3% (95% CI 43.8–76.3%), and 71.0% (95% CI 53.4–83.9%). In WC analysis, success rates for ≥50% arm NRS and NDI-5 were 0–4.3% lower between 1 and 12 months. PGIC scores were at least “much improved” or “very much improved,” in 48.4–65.6% of participants between 1 and 12 months. 6.1%, 6.1%, and 3.0% had one, two, or three repeat injections, respectively. 18.2% of participants underwent surgery by 12 months. Participants showed significant improvements in arm NRS and NDI-5 after treatment (p < 0.05), multilevel logistic regression models showed no significant decline in improvements across the follow-up time points (p > 0.05). ConclusionStatistically significant and clinically meaningful improvements in pain and disability were observed after CTFESI for up to 12 months in individuals with unilateral cervical radicular pain.

Benefit of pain and function after cervical transforaminal epidural steroid injections, an observational study

ObjectiveTo evaluate the improvement of pain and function after cervical transforaminal epidural steroid injections (CTFESI) for radicular pain. DesignThis is a retrospective observational study of patients receiving fluoroscopically-guided cervical transforaminal epidural steroid injections under a single provider at a tertiary referral center from December 2013 to December 2020. Primary outcome measures were Numeric Rating Scale (NRS), patient reported percent of pain relief, the Patient Health Questionnaire, the Patient Reported Outcome Measurement Information System (PROMIS) Global Health Physical and Mental Health score, and the Pain Disability Questionnaire. ResultsA total of 219 individual patients underwent 261 CTFESI and were included in the analyses. The average subject age was 51.9 years (SD = 11.3) and 50.9 % were male. Following the intervention, average pain relief by NRS at 3 months, 6 months, 1 year, and 2 years was −4.07, −3.82, −4.20, and −4.45, respectively. The average functional improvement with PROMIS-GH physical at 3-months, 6-months, 1- year, and 2-years was 2.23, 2.35, 3.15, and 3.29, respectively. ConclusionsOur results suggest that patients with cervical radiculopathy report significant pain relief and functional improvement following CTFESI. They can also report clinically important improvement in their health-related quality of life.

Inter-rater reliability of MRI superior articular process angle measurement for use in the modified approach to cervical transforaminal epidural steroid injections

BackgroundUpper extremity radicular pain is commonly treated with a cervical transforaminal epidural steroid injection (CTFESI). Recently, a new technique, the modified approach CTFESI, has been developed with a theoretical safety advantage to avoid the neurovascular structures. This approach requires an angle measurement of the superior articular process (SAP) on MRI. The inter-rater reliability of this angle measurement among practicing physicians is yet to be investigated. ObjectiveThe purpose of this study was to determine the inter-rater reliability of SAP angle measurements on MRI. MethodsThree raters independently measured the SAP angle on 50 cervical MRIs. A two-way, mixed effects, absolute agreement, single rater statistical model was used to determine the intraclass correlation coefficient (ICC) between all three raters, as well as between each pair of raters. ResultsInter-rater reliability among all raters showed good reliability with an ICC ​= ​0.837709 (95% CI 0.75–0.9, p ​< ​0.001). Similarly, good inter-rater reliability was found between each of the pairs of raters. ConclusionThis study demonstrates good inter-rater reliability of MRI SAP angle measurement among clinicians for use in the modified CTFESI approach.

The Retrodural Space of Okada Accessed During a Fluoroscopic Cervical Transforaminal Epidural Steroid Injection

The Retrodural Space of Okada Accessed During a Fluoroscopic Cervical Transforaminal Epidural Steroid Injection

The Effectiveness of Cervical Transforaminal Epidural Steroid Injections for the Treatment of Cervical Radicular Pain: A Prospective Cohort Study Reporting 12-month Outcomes

The Effectiveness of Cervical Transforaminal Epidural Steroid Injections for the Treatment of Cervical Radicular Pain: A Prospective Cohort Study Reporting 12-month Outcomes

20. Long-term results of cervical transforaminal epidural steroid injections for cervical radiculopathy

<h3>BACKGROUND CONTEXT</h3> Cervical radiculopathy can have significant effects on patient's pain and quality of life. Cervical transforaminal epidural steroid injections (TF ESIs) are thought to be high-risk procedures with limited longer-term effectiveness. <h3>PURPOSE</h3> To determine whether cervical TF ESIs improve patient reported quality of life outcomes, offer therapeutic benefit, and whether TF ESIs decrease the need to undergo cervical spine surgery. <h3>STUDY DESIGN/SETTING</h3> Academic hospital medical spine practice. <h3>PATIENT SAMPLE</h3> A total of 223 consecutive patients who underwent unilateral cervical TF ESI between 12/11/2013 and 12/23/2020. Average age was 51.8 (SD = 11.2 years) with 49.8% male, 50.2% female. Of the total, 3.8% were performed at C3-4, 9.5% at C4-5, 41.4% at C5-6, 38.0% at C6-7, and 7.2% at C7-T1. Median duration of symptoms was 9 months; 18.7% had previous cervical spine surgery; 19.8% had a repeat injection at the same level; 86.3% had IV sedation (Versed [midazolam]). Pathology 38.9% had disc herniation, 59.9 had bony foraminal stenosis, 1.1% had psedoarthrosis. Ninety-five percent had physicial therapy prior to cervical TF ESI. 35.5% had CT cervical spine and 40.8% had upper extremity EMG prior to cervical TF ESI. <h3>OUTCOME MEASURES</h3> We evaluated data using validated patient-reported outcomes measures – PHQ9, and PROMIS-GH Physical, and PROMIS-GH Mental. <h3>METHODS</h3> Retrospective review of single practitioner's outcomes after all patient undergoing cervical TF ESI from 2014-2020. <h3>RESULTS</h3> Of the 223 patients, 60 patients went on to have cervical surgery, 26.9%. Of the total patients, 92.8% had diagnostic benefit considered to be at least 80% immediate relief 4 hours after injection. History of spine surgery was the only statistically significant predictor to long-term benefit after cervical TF ESI. Patients who had prior spine surgery had a hazard of post-injection surgery that was 2.03 times larger, compared to patients who did not have prior spine surgery (P = 0.012). Mean PHQ-9 change of -1.53 at 3 months (p=0.016, n=91), -2.14 at 6 months (p= 0.006, n=53), -1.40 at 12 months (p= 0.056, n=61), -2.22 at 24 months (p=0.017, n=34). Mean PROMIS-GH physical change of +2.12 at 3 months (p=0.002, n=80), +2.22 at 6 months (p=0.005, n=55), +3.10 at 12 months (p=0.001, n=65), +3.23 at 24 months (p=0.001, n=38). History of cervical surgery was associated with worse PHQ-9 scores. <h3>CONCLUSIONS</h3> Cervical TF ESI can be done safely with minimal morbidity and significant benefit at 24 months. In more than 2/3 of the patients, surgery was not needed due to diagnostic and therapeutic benefit from cervical TF ESI. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

ID:16032 Trigger Points Accompanying Cervical Transforaminal Stenosis: A Hidden Cause of Remaining Pain Post TFESI

Cervical transforaminal epidural steroid injection (TFESI) is considered one of the most effective treatments for radicular pain induced by cervical foraminal stenosis. Studies have shown in 80% of patients who were surgical candidates, following TFESI, surgery was avoided. (1) The failure was mostly related to intensity of symptoms and history of previous episode of cervical radiculopathy. At the same time, it is well known that regional, persistent pain results in decreased range of motion in the affected and adjacent muscles which include muscles used to maintain body posture, such as those in the neck and shoulders.

Retrospective analysis of cervical transforaminal versus interlaminar epidural steroid injections

BackgroundSeveral studies have compared outcomes from lumbar epidural steroid injections (ESIs) based upon technique (transforaminal (TF) vs interlaminar (IL) vs caudal). However, little on this topic has been reported in the cervical spine, and results have been conflicting. PurposeTo compare success rates of fluoroscopically-guided cervical TFESIs vs ILESIs. Study design/settingRetrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sampleConsecutive patients who received a cervical TF or IL ESI between January 2010 and October 2018. Outcome measuresNRS pain scores within 60 days of the ESI. MethodsCurrent procedural terminology (CPT) codes were used to search all consecutive patients at a single outpatient academic spine center who received a cervical TF or IL ESI between January 2010 October 2018. All patients with pre and post injection NRS pain scores within 60 days of the injection were included in the analysis. ResultsA total of 178 ​TF and 185 ILESIs were analyzed. Success was defined as ≥ 50% improvement in NRS pain score. 52% [95% CI: 47 – 57%] of all patients receiving a cervical ESI achieved a successful outcome. There was a strong trend towards better results in the ILESI group with 59% [95% CI: 52 – 66%] of patients achieving at least 50% pain relief compared to 46% [95% CI: 39 – 53%] in the TF group. A higher proportion of patients in the IL group obtained at least 80% pain relief (37% [95% CI: 30 – 44%]) compared to those in the TF group (17% [95% CI: 11 – 23%]). Post-procedure median NRS pain scores, and improvement in median NRS pain scores were better in the ILESI group compared to the TFESI group (p<0.001). ConclusionThis retrospective study demonstrated better results in the cervical ILESI group compared to the cervical TFESI group.

The Retrodural Space of Okada Accessed During Cervical Transforaminal Epidural Steroid Injection.

The Retrodural Space of Okada Accessed During Cervical Transforaminal Epidural Steroid Injection.

Single center experience on the rate of discontinuation and safety of cervical transforaminal epidural steroid injections using the modified approach in an office setting without sedation

BackgroundCervical transforaminal epidural steroid injections (CTFESI) are commonly used in the treatment of upper extremity radicular pain. Recently, a modification of the conventional technique has been developed and validated which has a theoretical safety advantage of less risk of needle contact of the spinal nerve and vertebral artery. The new approach involves a needle trajectory under fluoroscopic guidance which is directly based upon the specific superior articular process angle measurement on MRI. ObjectiveThe purpose of this study was to evaluate the discontinuation rate of the modified approach CTFESI procedure in a non-sedated patient population. The study was also undertaken to confirm the safety of the procedure in an office-based setting. MethodsA retrospective review was performed of the authors' (DL, SH) practice to identify all CTFESI using the modified approach, performed between October 2018 through January 2021 through a query of the investigators’ (DL and SH) electronic medical record system. Any discontinued CTFESI procedure was identified. The reason for discontinuation was determined through medical record review. In addition, any significant neurologic or cardiovascular event occurring during or immediately following any completed or discontinued CTFESI was identified. Mild vasovagal reaction was not considered a significant complication. ResultsA total of 973 CTFESI procedures were performed using the modified approach during the study period. Twelve procedures, 1.2% (95% CI 0.7–2.1%) were discontinued. Nine were aborted due to vascular flow not resolved with needle repositioning. Only three, 0.3% (95% CI 0.1–0.9) were aborted due to patient intolerance. There were zero significant neurologic or cardiovascular complications. ConclusionThe performance of the modified approach CTFESI appears to be well tolerated with a very low rate, 0.3%, of discontinuation due to intolerance in non-sedated patients. The zero incidence of neurologic or cardiovascular complication contributes to the current literature on the safety of this procedure.

Injection into the Space of Okada During Transforaminal Epidural Steroid Injections.

Ensuring medication delivery to the epidural space is crucial for effective transforaminal epidural steroid injections. Epidural needle placement is determined by injecting a small amount of contrast at the final needle position. The purpose of this study is to illustrate the appearance of contrast flow in the retrodural retroligamentous space of Okada during computed tomography- and fluoroscopy-guided cervical and lumbar transforaminal epidural steroid injections. This retrospective study will use a series of cases to demonstrate contrast within the space of Okada during epidural transforaminal steroid injections. Tertiary medical center. Study subjects are adult patients who underwent transforaminal epidural steroid injection at our institution. Cases were identified through the use of a search engine of existing radiology reports at our institution. Epidural steroid injection procedural reports were searched for the terms "Okada" and "retrodural space." Images from the procedure were reviewed by the authors (all proceduralists with dedicated training in spinal injections) to confirm the presence of contrast within the space of Okada. This case series illustrates six examples of contrast injection into the retrodural space of Okada during cervical and lumbar transforaminal epidural steroid injections. Contrast uptake in the retrodural space of Okada may be seen during transforaminal epidural injections. Although relatively uncommon, it is likely underrecognized. It is extremely important that providers who perform transforaminal epidural steroid injections be familiar with this non-epidural contrast flow pattern so they can adjust needle positioning to deliver steroid to the epidural space.

Facet Joint Versus Transforaminal Epidural Steroid Injections in Patients With Cervical Radicular Pain due to Foraminal Stenosis: A Retrospective Comparative Study.

BackgroundA cervical transforaminal epidural (TFE) steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint (FJ) steroid injection can reduce cervical radicular pain through an indirect epidural spread. The aim of this retrospective comparative study was to evaluate the pain scores and functional disability in subjects receiving cervical FJ or TFE steroid injection for the treatment of cervical radicular pain due to foraminal stenosis (FS).MethodsWe selected 278 patients 18 years of age and older who underwent cervical FJ (n = 130) or TFE (n= 148) steroid injection for cervical radicular pain. The primary outcomes included pain scores and functional disability during hospital visits one, three, and six months after the initial injection. Secondary outcomes were the proportion of responders and Medication Quantification Scale (MQS) scores. Adverse events and variables correlating with effectiveness one month after the initial injection were also evaluated.ResultsThe Numeric Rating Scale and Neck Disability Index scores showed a significant improvement one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. There were no significant differences in MQS between the groups during the follow-up period. Univariate and multivariate logistic regression analyses revealed that the injection method, age, sex, number of injections, FS severity, MQS, pain duration, and the presence of cervical disc herniation were not independent predictors of treatment success.ConclusionThe efficacy of FJ steroid injection may not be inferior to that of TFE steroid injection in patients with cervical radicular pain due to FS.

Does the Severity of Neuroforaminal Stenosis Impact Short-Term Pain and Functional Outcomes After Cervical Transforaminal Epidural Steroid Injection? An Exploratory Analysis of Prospective Cohort Data

Does the Severity of Neuroforaminal Stenosis Impact Short-Term Pain and Functional Outcomes After Cervical Transforaminal Epidural Steroid Injection? An Exploratory Analysis of Prospective Cohort Data

Rate of Discontinuation for Cervical Transforaminal Epidural Steroid Injections Using the Modified Approach in an Office-based Setting Without Sedation

Rate of Discontinuation for Cervical Transforaminal Epidural Steroid Injections Using the Modified Approach in an Office-based Setting Without Sedation

Results of cervical epidural steroid injections based on the physician referral source

BackgroundMany patients who receive cervical epidural steroid injections (ESIs) are referred for the injection from a physician who does not perform the procedure. PurposeTo compare success rates of fluoroscopically-guided cervical ESIs in patients who had a clinical evaluation and recommendation for the injection by a fellowship-trained spine specialist who routinely performs ESIs (Group A), vs those who had a clinical evaluation by a fellowship-trained spine specialist who referred the patient for the procedure to be done by a different physician (Group B). Study design/settingRetrospective, observational, in vivo study of consecutive patients. Patient Sample. Patients undergoing cervical transforaminal (TF) or interlaminar (IL) ESIs at a single outpatient academic spine center. Outcome measuresNumeric Rating Scale (NRS) pain score improvement. MethodsCurrent procedural terminology (CPT) codes were used to search all consecutive patients who received a cervical TF or IL ESI between January 2010 and October 2018. All patients with pre and post-injection NRS pain scores within 60 days of the injection were included in the analysis. ResultsA total of 363 ESIs were analyzed (178 ​TF and 185 IL). 275 patients were evaluated and referred for the injection by a spine specialist who performs these procedures (Group A), and 88 were evaluated and referred by a spine specialist who does not perform these procedures (Group B). Success was defined as > 50% improvement in the NRS pain score. 52% [95% CI: 47–57%] of all patients who received a cervical ESI achieved a successful outcome. There were better results in Group A with a 57% [95% CI: 51–63%] success rate compared to a 38% [95% CI: 28–48%] success rate in Group B. Group A also had a higher proportion of patients who achieved at least 80% pain relief (31% [95% CI: 26–36%]) compared to Group B (17% [95% CI: 9–25%]). ConclusionThis retrospective study demonstrated better results from cervical ESIs when patients were referred for the injection by a physician who performs ESIs. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Contrast flow patterns based on needle tip position during cervical transforaminal epidural injections.

Few studies have evaluated the effect of final needle position on contrast flow patterns during the performance of cervical transforaminal epidural steroid injections (TFESIs). To analyze fluoroscopically guided cervical TFESI contrast flow patterns based upon final needle tip position. Retrospective, observational in vivo study. Outpatient private practice physical medicine and rehabilitation spine clinic. One hundred consecutive patients undergoing cervical TFESIs. Cervical TFESIs. Categories of contrast flow patterns including epidural, intraforaminal, "sufficient to inject," and "predominantly epidural and/or intraforaminal," based upon final needle tip position. Two independent observers reviewed images from 100 consecutive patients and classified injectate flow patterns stratified by needle tip position. The interrater reliability for all categories of interest was moderate, with kappa values from 0.61 to 0.76. More medially placed needles (middle third and lateral third of the articular pillars) resulted in higher rates of epidural contrast flow (75%; 95% confidence interval [CI]: 56%-94%; and 60%; 95% CI: 47%-73%) compared to needles placed lateral to the articular pillars (26%; 95% CI: 8%-44%), and higher rates of "predominantly epidural and/or intraforaminal" flow patterns with needles placed in the middle one third (75%; 95% CI: 56%-94%) and lateral one third of the articular pillars (47%; 95% CI: 34%-60%) compared to flow patterns when needles were placed lateral to the articular pillars (17%; 95% CI: 2%-32%). No needles were placed in the medial third of the articular pillars. More medially placed needle tips result in more optimal flow patterns during cervical TFESIs. The importance of this finding is unknown as clinical outcomes were not measured.

Does the Contrast Dispersion Pattern During Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection Predict Short-Term Pain and Functional Outcomes? An Exploratory Analysis of Prospective Cohort Data

No study has evaluated the relationship between contrast dispersion patterns and outcomes after fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI). Determine whether contrast dispersion patterns predict pain and functional outcomes after CTFESI. Secondary analysis of data collected during two prospective studies of CTFESI for the treatment of refractory radicular pain. Contrast dispersion patterns visualized by true anteroposterior (AP) projections during CTFESIs were categorized by flow: 1)completely external to the lateral border of the neuroforamen (zone 1); 2)within the neuroforamen but without entry into the lateral epidural space (zone 2); and 3)with extension into the lateral epidural space (zone 3). At baseline and at 1 month post-CTFESI, neck pain, arm pain, and "dominant index pain" (the greater of arm or neck pain) were evaluated using a numeric rating scale (NRS); physical function was assessed using the Five-Item Version of the Neck Disability Index (NDI-5). One-month post-CTFESI, neck pain, arm pain, and "dominant index pain" reductions of ≥50% were observed in 39.4% (95% confidence interval [CI], 28.2-51.8), 55.6% (95% CI, 43.0-67.5), and 44.1% (95% CI, 32.7-56.2) of participants, respectively. Regarding "dominant index pain," 72.7% (95% CI, 40.8-91.2), 39.4% (95% CI, 24.2-57.0), and 37.5% (95% CI, 20.5-58.2) of participants reported ≥50% pain reduction when zone 1, zone 2, and zone 3 contrast flow patterns were observed. Contrast dispersion zone was not significantly associated with subgroup differences in neck pain, arm pain, or NDI-5 scores (P>0.05). Improvements in pain and function 1 month after treatment with CTFESI did not differ significantly based on the contrast dispersion pattern. Future study is needed to confirm or refute these findings in other procedural settings, in broader patient populations, and with longer-term outcome assessment.

Modification of the Cervical Transforaminal Epidural Steroid Injection Technique Based Upon the Anatomic Angle of the Superior Articular Process on MRI.

A modification of the conventional technique for cervical transforaminal epidural steroid injection (CTFESI) has been developed. This technique may, theoretically, decrease the likelihood of the needle encountering the vertebral artery and spinal nerve. The approach uses angle measurements of the superior articular process ventral surface from the patient's axial MRI as a guide for fluoroscopic set-up and needle trajectory. This report aims to compare contrast flow patterns of the modified approach with those of the conventional technique. Retrospective chart review and prospective blinded analysis of contrast flow patterns. Setting. Outpatient interventional physiatry practice. A retrospective blinded qualitative review of fluoroscopic images was performed to compare contrast flow patterns of CTFESIs performed using the modified approach with those using the conventional technique. A detailed description of the modified approach is provided in this report. Ninety-seven CTFESI procedures were used for flow analysis. The modified approach resulted in a statistically significant greater percentage of injections with epidural flow: 69% [95% CI = 57-82%] modified approach vs. 42% [95% CI = 28-56%] conventional approach. The modified technique also showed a statistically significant higher percent of injections categorized as having an ideal flow pattern, that of predominate epidural and/or intraforaminal flow: 65% [95% CI = 52-78%] vs. 27% [95% CI = 14-40%]. A modification of the conventional CTFESI technique, developed for the purpose of improved safety, may provide superior contrast flow patterns when compared to the conventional approach.