Lumbar Transforaminal Epidural Steroid Injections Research Articles

Contrast Dispersal Patterns as a Predictor of Clinical Outcome With Transforaminal Epidural Steroid Injection for Lumbar Radiculopathy

To assess the relationship between epidural contrast dispersal patterns from lumbar transforaminal epidural steroid injections (TFESIs) and both immediate- and short-term pain reduction. We also investigated the effect of the grade of nerve root compression on contrast dispersal pattern and pain reduction. Retrospective review of data from a previous prospective study of outcomes after TFESI. Academic spine and musculoskeletal clinic. Thirty-eight subjects who underwent single-level lumbar TFESI for unilateral lumbar radicular pain. A retrospective assessment of a digital database of TFESIs for unilateral lumbar radicular pain. Type of contrast pattern was analyzed by 2 physiatrists as type I (tubular appearance); type II (nerve root visible as a filling defect); or type III (cloudlike appearance). Grade of nerve root compression on magnetic resonance also was analyzed by 2 physiatrists as grade I abutment, grade II displacement, or grade III entrapment. Effect of type of contrast pattern and grade of nerve root compression on change in Numeric Pain Rating Scale (NPRS) at time of injection (T1), 2 weeks after (T2), and 2 months after (T3). Mean decrease in NPRS at all time points was statistically significant with both types I and III contrast dispersal patterns. Groups with grades II and III nerve root compression had statistically significant reductions in NPRS at all time points. In this retrospective review we found that TFESIs can have an immediate beneficial effect on pain regardless of contrast pattern type or grade of nerve root compression. Subjects with higher grades of nerve root compression and a type I or III contrast pattern have significantly greater reductions in pain at 15 minutes, 2 weeks, and 2 months. Our findings are limited by methodological restrictions, and further confirmation with a prospective trial to review other possible associated factors is recommended.

Poster 331 Fear Avoidance Behaviors and Mindfulness in Successful Outcomes of Lumbar Transforaminal Epidural Steroid Injections in Patients With Back Pain

Poster 331 Fear Avoidance Behaviors and Mindfulness in Successful Outcomes of Lumbar Transforaminal Epidural Steroid Injections in Patients With Back Pain

Lumbar Retrodiscal Versus Post-Ganglionic Transforaminal Epidural Steroid Injection for the Treatment of Lumbar Intervertebral Disc Herniations

Background: Lumbar transforaminal epidural steroid injections (TFESIs) are procedures often utilized in the treatment of radicular pain. TFESIs with a preganglionic approach have been reported to be more effective than TFESIs performed using a classic approach. However, it is unknown whether TFESIs using a retrodiscal approach are as effective as other approaches. Objective: To investigate the effect of an epidural steroid injection (ESI) on radicular pain, we conducted a randomized, controlled trial comparing a retrodiscal approach with a classic approach to treat lumbar disc herniation. Design: A case control study. Methods: Forty patients were randomized to receive lumbar TFESIs with either a retrodiscal approach (n=20) or with a classic approach (n=20). Measurements were taken before as well as 4 and 8 weeks after treatment using a visual analog scale (VAS) score, Patient Satisfaction Index (PSI) and the Roland 5-point pain score. Results: In the retrodiscal group, there was a statistically significant improvement in the VAS score after injection compared to baseline. In the classic group, there was a statistically significant improvement in the VAS score after injection compared to baseline. There was no statistically significant difference in the VAS score, PSI, or the Roland 5-point pain score between those treated with a retrodiscal approache and those treated with a classic approach. Limitations: Secondary outcomes were not measured and the study did not include a midor long-term follow-up period. Conclusion: In this study, TFESIs performed using a retrodiscal or classic approach had similar effects on radicular pain. The classic and the retrodiscal transforaminal steroid injection resulted in equivalent pain relief. . Key words: Corticosteroids, lumbar disc herniation, radicular pain, retrodiscal, transforaminal epidural injection

The Complications of Transforaminal Lumbar Epidural Steroid Injections

A prospective observational study. In this study, we aimed to investigate the major and minor complications of transforaminal lumbar epidural steroid injections guided by fluoroscopy and the incidence of vascular penetration encountered during this procedure. Epidural steroid administration is one of the treatment options for lumbar disc hernia accompanied by radiculopathy. This method, initially applied by blind interlaminar technique, has generally been performed by fluoroscopically guided transforaminal method now. The complications of this method cause to a serious concern. The complications of this intervention have been reported by either mostly retrospective studies or case reports until now. Prospective studies with large patient series are needed to determine the types and incidences of the complications. In this study carried out for more than 5 years, major and minor complications of transforaminal lumbar epidural steroid injections were investigated prospectively. All of the interventions were performed under fluoroscopic guidance by the same physician using a standardized method. A follow-up was made once in the third week. The complications encountered during the procedure and in the third week were prospectively recorded. In addition, the incidence of vascular penetration that is potentially hazardous is included in the study. A total of 562 patients were performed 1305 times transforaminal lumbar epidural steroid. The overall incidence of vascular penetration encountered was 7.4%. Although major complications were not seen, the total rate of all minor complications was 11.5%. Whereas all of the minor complications were transient, the most frequent minor complication was vasovagal reaction (8.7%). On the basis of the results of this study in which only minor complications were encountered, it can be said that the frequency of major complications is pretty rare in transforaminal lumbar epidural steroid injections in expert hands and in the conditions in which safety precautions are taken.

Dermatomal Skin Rash After Lumbar Epidural Steroid Injection

the objective of this case is to report an occurrence of a skin rash in a dermatomal distribution subsequent to a lumbar transforaminal epidural steroid injection. in this clinical report, a 54-year old woman performed a left L5 transforaminal epidural steroid injection to manage left thigh and foot pain and tingling. She developed a rash in left L5 dermatomal distribution following injection. this is the first described case of a focal dermatomal rash occurring following lumbar transforaminal epidural steroid injection and we wish to remind pain practitioner’s of the possibility of anaphylactic events.

Prognostic Usefulness of High Sensitivity C-Reactive Protein for Transforaminal Epidural Steroid Injection in Patients with Radicular Pain

There are several types of lumbar stenosis, such as central, lateral recess, foraminal. The symptoms of lumbar stenosis are neurogenic claudication, numbness, tingling, etc. The treatment modality is medication, physical therapy, intervention, and surgery. The epidural steroid injection has been used for treatment of low back pain/radiculopathy. However, we could not predict what percent had pain relief after epidural steroid injection. The purpose of this study was to evaluate the usefulness of high sensitivity C-reactive protein (hsCRP) as a marker for predicting the efficacy of lumbar transforaminal epidural steroid injection. A total of 55 patients with lumbar stenosis underwent lumbar transforaminal epidural steroid injection under fluoroscopic guidance. Prior to injection, all patients were examined and their visual analog scale (VAS) score and hsCRP score were recorded. They returned 4 weeks following their initial injection and repeat hsCRP, and VAS sores were obtained. The average pretreatment hsCRP and VAS score for all 55 patients were 3.2±4.3 mg/L and 8.1±1.1, respectively. Forty-two of 55 patients had 1.6 mg/L of hsCRP. After procedure, the VAS decreased from 8.0±1.1 to 2.5±1.1. In contrast, the averages of hsCRP and VAS scores of 13 patients were 9.4±3.7 mg/L and 8.2±0.9, respectively, at baseline, which decreased to 1.2±0.9 mg/L and 2.5±0.8 at 4 weeks later. At posttreatment, the VAS score difference between the two groups was not statistically significant. There was no correlation between hsCRP and VAS score (P=0.426). The results suggest that there was no correlation between pretreat hsCRP and posttreat VAS. Therefore, hsCRP may not be useful as predictor of response to TFESI in patients with spinal stenosis.

Assessment of the effectiveness of lumbar transforaminal epidural steroid injection for low back pain

Transforaminal epidural steroid injection (TFESI) is a minimally invasive technique used for low back pain. We aimed to assess the efficiency of TFESI in patients with low back pain who did not respond to conservative or surgical methods. This study was a retrospective analysis of the records of 37 patients (range: 24-80 years) who presented to our clinic with low back pain and were treated by TFESI. Outcomes were assessed by Visual Analog Scale (VAS) measured at the 3rd week and 6th month. Median age of the patients was 50 years, and mean duration of symptoms was 48 months. Diagnosis was lumbar disc herniation (LDH) in 51%, failed back surgery syndrome (FBSS) in 38%, and spinal stenosis (SS) in 11% of the patients. Baseline VAS scores were similar between the three groups. The 3rd week and 6th month VAS scores of LDH and FBSS cases were significantly decreased compared to baseline scores (p<0.001, p=0.001), and no significant change was observed between the VAS scores at the 3rd week and 6th month (p>0.05). If success is defined as 50% or more decrease in VAS scores, the success rate of TFESI was 84% at the 3rd week and 78% at the 6th month. TFESI significantly reduced the intensity of low back pain in most of the patients with LDH, FBSS or SS; thus, it may be considered as an effective method in the treatment of low back pain.

Transforaminal epidural steroid injection via a preganglionic approach for the treatment of lumbar radicular pain

To evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) for lumbar radiculopathy with respect to effect of injection levels, gender, and age group. Hundred-fifty-three consecutive patients who underwent to lumbar TFESI were enrolled. The outcomes were measured by using a visual numeric scale (VNS), NASS and EQ-5D. The relationship between possible outcome predictors and the therapeutic effect were evaluated. All the patients completed the 2nd year follow-up visits. Significant differences were observed between the pre-procedure and post-procedure VNSs, NASS patients' satisfactions scores and EQ-5D (P < 0.01) except 1st and 2nd year follow-up (P=0.12, P=0.27and P=0.19 respectively). Gender (higher in female patients) showed significant effect to pre-procedure VNS (P=0.04). An increase in the level number was significantly associated with an increase in the 6th month (P=0.005, P=0.004 respectively) and the 1st year (P=0.05, P=0.029 respectively) NASS and EQ-5D. No complication was occurred except discitis in two chronic renal failure patients. Especially in the patients with severe co-morbidities TFESI is an option to provide higher life quality. The clinical course of the success of the TFESI decreases in one year and becomes stable thereafter. In the patients with immune deficiency, the practitioners should always be aware for an infectious complication.

Inadvertent Intradiscal Contrast Flow During Lumbar Transforaminal Epidural Steroid Injections: A Case Series Examining the Prevalence of Intradiscal Injection as well as Potential Associated Factors and Adverse Events

The primary aim was to evaluate the prevalence of inadvertent intradiscal injection during fluoroscopically guided contrast-enhanced lumbar transforaminal epidural steroid injections. The secondary aim was to determine if there are any risk factors for or adverse events as a result of inadvertent intradiscal contrast injection. The study was a retrospective case series. The study was set in three outpatient spine care centers. A search was conducted in a database of spinal injection procedures from July 2000-May 2008. Fifteen cases of inadvertent intradiscal contrast flow were identified. These cases were matched with one control case with the same age, gender, level, and side of injection. The prevalence of intradiscal contrast flow with lumbar transforaminal epidural steroid injection was calculated. Chart review of the cases and controls was performed. An independent, blinded examiner evaluated needle tip placement. Frequency of intradiscal contrast flow during lumbar transforaminal epidural steroid injections and the relationship between the occurrence of intradiscal contrast flow with potential risk factors. The prevalence of inadvertent intradiscal injection during lumbar transforaminal epidural steroid injections was 0.17%. All of the patients received prophylactic antibiotics after inadvertent disk injection, and there were no infectious or other complications identified. Intradiscal contrast injection is an infrequently reported event during lumbar transforaminal epidural steroid injections. Our data support that the prevalence is very low and there might be an association with ipsilateral foraminal stenosis. Although there is potential for significant adverse complications with intradiscal injection, our data set did not show serious sequelae.

Comparison of the Effectiveness of Lumbar Transforaminal Epidural Injection with Particulate and Nonparticulate Corticosteroids in Lumbar Radiating Pain

Lumbar transforaminal epidural steroid injections are procedures often utilized in the treatment of low back pain associated with radicular pain. Particulate steroids have been known to play a role in embolism. It is, unknown whether nonparticulate steroids are as effective as particulate steroids. To investigate the effect of an epidural steroid injection on back pain, we conducted a randomized, controlled trial comparing nonparticulate steroid with particulate steroid to treat lumbar disc herniation. One hundred-six patients were randomized to receive lumbar transforaminal epidural steroid injections (N = 53) with either dexamethasone 7.5 mg, or with triamcinolone acetate 40 mg (N = 53). Measurement were taken before treatment and one month after treatment using a visual analog scale, short McGill pain questionnaire, and revised Oswertry Back Disability Index. There was a statistically significant difference in the visual analog score between those treated with dexamethasone and those given triamcinolone. The two groups did not differ significantly on the McGill Pain Questionnaire, or the Oswestry Disability Index before and after treatment. In this study, dexamethasone and triamcinolone treatments were shown to have different effects on low back pain with sciatica, with triamcinolone being more effective than dexamethsone in lumbar radiculopathy.

Efficacy of Fluoroscopically Guided, Contrast-Enhanced Lumbosacral Interlaminar Epidural Steroid Injections: A Pilot Study

To assess the efficacy of fluoroscopically guided, contrast-enhanced lumbar interlaminar epidural steroid injections (IL-ESI) for lower limb pain greater than axial low back pain using self-reported pain scores. Prospective, single-arm, pilot, observational human study. An outpatient private practice interventional spine specialty referral center. Twenty-one patients were initially included in analysis. Thirteen patients had "complete data" and completed 3 months of data after their most recent IL-ESI. Their self-reported 3-day average Numeric Pain Rating Scale (NPRS) score (0 to 10) at inception, 2 weeks, 6 weeks, and 3 months were 6.38, 3.00, 2.88, and 3.04, respectively. The average NPRS score at 3 months was significantly lower than at inception after the IL-ESI for this group (P = 0.0001, 95% confidence interval [1.69, 5.00]). Eight patients had "incomplete data." Their self-reported 3-day average NPRS scores at inception, 2 weeks, and 6 weeks were 6.69, 4.25, and 4.00, respectively. Of the eight patients who had incomplete data, two patients had surgical intervention, five patients had lumbar transforaminal epidural steroid injections, and one patient was unable to be contacted after 6 weeks. This prospective, single-arm pilot study demonstrates that subjects who have had fluoroscopically guided, contrast-enhanced lumbar IL-ESIs for radicular > axial pain can have improved (lowered) NPRS for at least 3 months. It would be worthwhile to pursue a more rigorous study.

Poster 349: Length of Fluoroscopy Used During Transforaminal Lumbar Epidural Steroid Injections as a Measure of Trainee Competency

Poster 349: Length of Fluoroscopy Used During Transforaminal Lumbar Epidural Steroid Injections as a Measure of Trainee Competency

Incidental discogram during an attempted lumbar transforaminal epidural steroid injection

Incidental discogram during an attempted lumbar transforaminal epidural steroid injection

Reducing the Risk of Spinal Cord Infarction during Transforaminal Steroid Injections

We read with great interest the recent report by Lyders and Morris[1][1] of their case of spinal cord infarction following lumbar transforaminal epidural steroid injection. We would like to highlight the fact that not all corticosteroid preparations are associated with the same risk of embolization

Poster 259: Inadvertant Intradiskal Contrast Flow During Lumbar Transforaminal Epidural Steroid Injections: A Case Series Examining the Occurrence of Intradiskal Injection as well as Potential Risk Factors and Adverse Events

PM&RVolume 1, Issue 9S p. S216-S216 Poster Presentation Poster 259: Inadvertant Intradiskal Contrast Flow During Lumbar Transforaminal Epidural Steroid Injections: A Case Series Examining the Occurrence of Intradiskal Injection as well as Potential Risk Factors and Adverse Events Ellen K. Casey MD, Ellen K. Casey MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorLarry H. Chou MD, Larry H. Chou MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorBradly S. Goodman MD, Bradly S. Goodman MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorChris Plastaras MD, Chris Plastaras MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorDaniel C. Roth DO MBA MS, Daniel C. Roth DO MBA MS Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this author Ellen K. Casey MD, Ellen K. Casey MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorLarry H. Chou MD, Larry H. Chou MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorBradly S. Goodman MD, Bradly S. Goodman MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorChris Plastaras MD, Chris Plastaras MD Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this authorDaniel C. Roth DO MBA MS, Daniel C. Roth DO MBA MS Rehabilitation Institute of Chicago, Chicago, ILSearch for more papers by this author First published: 25 September 2009 https://doi.org/10.1016/j.pmrj.2009.08.281Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume1, Issue9SSeptember 2009Pages S216-S216 RelatedInformation

Radicular Pain in a Patient with Aqueductal Cerebral Stenosis

A 53-year-old man with no significant medical history presented with sciatica of several months’ duration. He also reported a 5-year history of intermittent pain in the lower back. He described dysesthesia along the posterolateral aspect of the thigh, anterior aspect of the leg, and dorsum of the foot with an intensity of 6 of 10. There were no precipitating factors, and his pain did not change with sitting, standing, or walking. He also described numbness along the anterior aspect of the leg and dorsum of the foot, but did not experience any weakness. Magnetic resonance imaging (MRI) of his lumbosacral spine performed a few days before the initial evaluation revealed multilevel degenerative changes without any evidence of disk herniation, or central or foraminal stenosis. On review of systems he reported mild intermittent headaches. Headaches were described as global, pressure type with no associated symptoms. He reported no bladder or bowelincontinence,nogaitorbalancedisturbances,oranyvisualdisturbances.Onphysical examination a positive straight leg raise test was noted on the right at 60°. Cranial nerve examination, muscle strength, deep tendon reflexes, and sensory examination were otherwise unremarkable. Two lumbar transforaminal epidural steroid injections were performed at the right L5 neural foramen 4 weeks apart. In each procedure, the injectate consisted of 80 mg of triamcinolone and 1 mL of 1% lidocaine. Each injection provided him with 2 weeks of pain relief. Pregabalin 75 mg twice a day was initiated and provided him with partial relief of his symptoms. Three months after the initial evaluation, he continued to experience prominent radicular symptoms. He also noted progressively worsening headaches described as global and pressure type. The patient also reported visual disturbances with a decrease in visual acuity. Funduscopic examination revealed mild papilledema. An MRI of the brain was obtained that revealed enlargement of the lateral ventricles bilaterally and mild enlargement of the

A Case of Spinal Cord Infarction Following Lumbar Transforaminal Epidural Steroid Injection: MR Imaging and Angiographic Findings

Spinal cord infarction following lumbar transforaminal epidural steroid injection is a rare and devastating complication. We describe the case of a 55-year-old woman who developed spinal cord infarction following right L2-3 transforaminal epidural injection, diagnosed on the basis of clinical and MR imaging findings. Spinal angiography demonstrated occlusion of the right L2 segmental artery with reconstitution of the radicular branch from collaterals. The artery of Adamkeiwicz could not be demonstrated and was presumably occluded by the steroid injection.

A prospective, observational study of the relationship between body mass index and depth of the epidural space during lumbar transforaminal epidural steroid injection.

Previous studies have concluded that transforaminal epidural steroid injections (ESIs) are more effective than interlaminar injections in the treatment of radiculopathies due to lumbar intervertebral disk herniation. There are no published studies examining the depth of epidural space using a transforaminal approach. We investigated the relationship between body mass index (BMI) and the depth of the epidural space during lumbar transforaminal ESIs. Eighty-six consecutive patients undergoing lumbar transforaminal ESI at the L3-L4, L4-L5, and L5-S1 levels were studied. Using standard protocol, the foraminal epidural space was attained using fluoroscopic guidance. The measured distance from needle tip to skin was recorded (depth to foraminal epidural space). The differences in the needle depth and BMI were analyzed using regression analysis. Needle depth was positively associated with BMI (regression coefficient [RC], 1.13; P < 0.001). The median depths (in centimeters) to the epidural space were 6.3, 7.5, 8.4, 10.0, 10.4, and 12.2 for underweight, normal, preobese, obese I, obese II, and obese III classifications, respectively. Sex (RC, 1.3; P = 0.02) and race (RC, 0.8; P = 0.04) were also significantly associated with needle depth; however, neither factor remained significant when BMI was accounted as a covariate in the regression model. Age, intervertebral level treated, and oblique angle had no predictive value on foraminal depth (P > 0.2). There is a positive association between BMI and transforaminal epidural depth, but not with age, sex, race, oblique angle, or intervertebral level.

Systematic Review of Therapeutic Lumbar Transforaminal Epidural Steroid Injections

Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. The transforaminal route to the lumbar epidural space for steroid injection has gained rapid and widespread acceptance for the treatment of lumbar and leg pain. However, there are few well-designed randomized, controlled studies to determine the effectiveness of epidural injections. The role and value of transforaminal lumbar epidural steroid injections is still questioned. A systematic review of transforaminal epidural injection therapy for low back and lower extremity pain. To evaluate the effect of transforaminal lumbar epidural steroid injections in managing lumbar (low-back) and sciatica (leg) pain. The available literature of lumbar transforaminal epidural injections in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of the bibliographies of known primary and review articles. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. The indicated evidence is Level II-1 for short-term relief and Level II-2 for long-term relief in managing chronic low back and lower extremity pain. The limitations of this systematic review include the paucity of literature. The indicated evidence for transforaminal lumbar epidural steroid injections is Level II-1 for short-term relief and Level II-2 for long-term improvement in the management of lumbar nerve root and low back pain.

Poster 232: Contrast Flow Distribution During Lumbar Transforaminal Epidural Injections Contrast Flow Distribution During Lumbar Transforaminal Epidural Injections

Objective: To assess and quantitate the epidural contrast flow patterns noted during fluoroscopically guided lumbar transforaminal epidural steroid injections. Design: After confirming appropriate spinal needle position with biplanar imaging, Nonionic contrast was slowly injected. Fluoroscopic images were recorded and evaluated to document the extent of contrast spread to specific fluoroscopic landmarks. Setting: Academic/private pain management and physiatric practice and ambulatory surgical center. Participants: 61 patients undergoing lumbar transforaminal epidural steroid injections were investigated. Interventions: Lumbar transforaminal epidural steroid injections are an accepted treatment in the comprehensive, conservative care for low back and buttock pain with a radicular component secondary to intervertebral disk (IVD) pathology or spinal stenosis. The total volume(s) of injectate described in the literature varies from 1cc to 5cc. Recommendations exist regarding the appropriate total volume to be used to limit injectate spread to a single level. There is no literature describing the contrast flow patterns to specific therapeutic landmarks during lumbar transforaminal epidural steroid injections. Main Outcome Measures: Specifically, injectate volumes were recorded as contrast flowed to the ipsilateral pedicle and subsequently to the superior aspect of the superior IVD space and inferior aspect of the inferior IVD space. We also evaluated and quantitated contra-lateral flow as well. Results: Contrast injections of 3.0cc reached the superior IVD 95% of the time, the inferior IVD 90% of the time, and both the superior and inferior IVD 85% of the time. This improves to 88% with no surgical history. Almost no patients demonstrated contralateral flow. Conclusions: When performing therapeutic lumbar transforaminal epidural steroid injections, consider limiting injectate to 3.0cc to treat pathology superior to and inferior to the foraminal level, regardless of whether the diagnosis is IVD or cental stenosis. If treating bilateral pathology, bilateral procedures are recommended.