Objective: To determine if medication delivery into epidural space confirmed by contrast enhancement fluoroscopic images is superior to a neurogram placement; to determine if lumbar transforaminal epidural steroid injections needle position can effect contrast spread pattern and outcome. Design: Prospective, evaluator-blind clinical trial. Setting: Outpatient multidisciplinary spine care center. Participants: 50 patients with L4 and/or L5 radiculopathy who failed conservative management. Interventions: L4-L5 and/or L5-S1 lumbar transforaminal epidural steroid injections. Main Outcome Measures: A survey that included Verbal Rating Scale (VRS), visual analog scale (VAS), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Pain Catastrophizing Scale (PCS). Fluoroscopic radiographs reviewed by a radiologist blinded to the patient and outcome to identify needle position (AP/lateral views) and contrast flow. With the AP view, the radiologist determined the needle point to be at medial or lateral by using the 6 o'clock position as midline. In the lateral view, the location of the needle tip was classified as 12 o'clock, 3 o'clock, 6 o'clock, or 9 o'clock position. Results: 68% of patients were women and 32% were men, with average age ± SD of 56.7±14.9 years (range, 19–86y). At the L4-L5 level, 58% were neurograms, 0% epidural only, and 26% with both patterns. At the L5-S1 level, 48% were neurograms, 6% epidural, and 44% had both patterns. There were no statistically significant differences between needle position and functional outcome using the VRS, VAS, and ODI. There appeared to be a trend for better outcome as measured by change in VRS, VAS, HADS, and ODI for epidural contrast pattern. Interestingly, there was a trend for worse PCS scores in the epidural group when compared with the neurogram-only group. Conclusions: These findings suggest that there is no benefit in functional outcome as related to needle position within the foramina. It is likely that regardless of needle position, epidural spread of the medication is the more important factor in functional improvement with lumbar transforaminal epidural steroid injections. Limitations include small sample size and possible overlapping effect with multi-level injections. Further studies with larger sample size are needed to address outcome improvement in correlation with fluoroscopic images.