Editor-in-Chief: Alaa Abd-Elsayed, MD, PhD
A subpedicular transforaminal epidural steroid injection (TFESI) at the L5-S1 level can be technically challenging due to lumbar spondylosis. As described in the cases below, in challenging cases, placing multiple needles (normally 2 needles, occasionally 3 needles) before injecting the radiocontrast dye can improve the chances of depositing the steroid in the area of pathology responsible for pain. This will, of course, add to the risk of the procedure due to multiple needles being close to the nerve root. On balance, however, it may be less risky than not placing the steroid at the appropriate pathological site, which may fail to provide pain relief leading to unnecessary suffering and, in some cases, surgical intervention. However, if the spread of contrast medium and the subsequent steroid injection through the first needle is satisfactory, then the other needles can be removed without injecting. The “pre-contrast injection multiple needle placement” technique has been used by the author on multiple occasions and 3 cases are described below.
KEY WORDS: Epidural steroid injection, transforaminal epidural injection, sciatica, radicular pain, multiple needle technique