Figure 1. Anteroposterior radiograph shows degenerative changes in the lumbar spine.
Figure 2. Lateral view of the lumbar spine.
A 52-year-old patient presents with lower back pain with radiation to the right lower extremity. The pain radiates down the posterior leg to the right foot with the occasional numbness in the foot. The pain started after a work-related injury 2 years ago and has been intermittent since. He has tried physical therapy (PT) and home exercises over the past 6 months with some relief but his symptoms have returned. The patient works as a floor installer and notes that he can’t stand or walk for long periods of time because the pain will start to shoot down his right leg. He has not found nonsteroidal anti-inflammatory drugs (NSAIDs) to be helpful.
On physical examination, the patient has aching pain across his lower back and difficulty with bending, twisting, and walking. He has a positive straight leg raise on the right with pain down the right leg. His motor strength and sensation are intact in his lower extremities. Radiographs show degenerative changes in the lumbar spine with levoscoliosis (Figurse 1 and 2). Magnetic resonance imaging (MRI) of the lumbar spine shows foraminal stenosis on the right side at L3-L4.
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Lower back pain with radiculopathy is one of the most common complaints seen in a health care setting. Most patients can be treated successfully with 2 to 3 months of conservative treatment such as PT, NSAIDs, oral corticosteroid therapy, chiropractic treatment, and acupuncture. When patients fail these conservative treatments, fluoroscopic-guided lumbar spinal injections are often the last resort for pain relief before surgical intervention is considered.1,2
Fluoroscopic-guided lumbar steroid injections are the most common injection technique used to treat lumbar spine pain with and without radiculopathy. Steroids relieve pain by targeting inflammation that causes a chemical irritation of the nerve root. Lumbar epidural injections are generally performed with an interlaminar or transforaminal approach. With the interlaminar approach, the medication is delivered into the posterior epidural space. The lumbar transforaminal approach is more technically demanding as the needle is inserted close to the nerve root as it exits the neuroforamen. The benefit of the transforaminal approach is that the steroid is injected closer to the anterior epidural space where most disc and nerve root pathology occurs.1,2
Transforaminal epidural steroid injections are the treatment of choice for patients with worsening radicular pain. Lumbar epidural injections are an effective short- and long-term treatment option for patients. The majority of patients (>75%) who have failed other conservative options will get relief and avoid the need for surgery.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Manchikanti L, Knezevic NN, Navani A, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician. 2021;24(S1):S27-S208.
2. Young IA, Hyman GS, Packia-Raj L, Cole AJ. The use of lumbar epidural/transforaminal steroids for managing spinal disease. J Am Acad Orthop Surg. 2007;15(4):228-238. doi:10.5435/00124635-200704000-00006