Are transforaminal epidural steroid injections (TFESIs) recommended for a patient who is status post lumbar decompression surgery and experiencing a return of radicular symptoms?

Transforaminal Epidural Steroid Injections for Post-Lumbar Decompression Recurrent Radicular Pain

Transforaminal epidural steroid injections (TFESIs) are recommended for patients with recurrent radicular symptoms after lumbar decompression surgery, particularly when there is MRI evidence of nerve root compression. 1

Indications and Evidence Support

• TFESIs are strongly recommended by the American Society of Anesthesiologists for patients with radicular pain or radiculopathy, which would include post-surgical recurrence of radicular symptoms 1
• Patients must demonstrate clinical signs of radiculopathy with pain radiating below the knee to meet criteria for TFESI authorization 1
• The American College of Physicians recommends that patients with persistent low back pain and signs/symptoms of radiculopathy should be evaluated with MRI if they are potential candidates for epidural steroid injection 2

Patient Selection Criteria

• MRI evidence of pathology such as nerve root compression or moderate to severe disc herniation should be present to justify TFESI 1
• The patient should have failed conservative management for at least 4 weeks before considering TFESI 1
• Radicular pain is specifically defined as pain and/or numbness that radiates below the knee, which is a requirement for TFESI authorization 1

Technical Considerations

• Image guidance with fluoroscopy is essential for transforaminal epidural injections to ensure proper needle placement and reduce the risk of complications 1, 3
• The transforaminal approach requires particular attention to technique due to its higher risk profile compared to interlaminar approaches 1

Efficacy in Post-Surgical Patients

• Observational studies have shown that TFESIs can be effective in patients with lumbar spinal stenosis, with 44% of patients satisfied with non-surgical management at 2 years after TFESI 4
• The efficacy of TFESI is influenced by the severity of foraminal stenosis, with better outcomes observed in mild to moderate stenosis compared to severe stenosis 5
• Long-term studies (5+ years) show that while many patients experience recurrence of symptoms over time, TFESIs can provide effective short-term relief and may help avoid surgery in some cases 6, 7

Risks and Complications

• Potential complications include dural puncture, insertion-site infections, sensorimotor deficits, and retinal complications 1
• Shared decision-making regarding this procedure should include discussion of these potential complications 1

Contraindications

• TFESIs are not recommended for non-radicular low back pain according to the American College of Physicians and the American Academy of Neurology 1, 3
• The diagnosis must specifically include radiculopathy for TFESI to be considered medically necessary 3

Treatment Algorithm

1. Confirm recurrent radicular symptoms (pain radiating below the knee) after lumbar decompression surgery 1
2. Obtain MRI to document nerve root compression or disc herniation 2, 1
3. Ensure patient has attempted at least 4 weeks of conservative management 1
4. If symptoms persist and imaging confirms pathology, proceed with TFESI under fluoroscopic guidance 1
5. Evaluate response at 2-4 weeks; consider repeat injection if partial response is observed 8
6. For patients with inadequate response, consider alternative diagnoses or surgical consultation 1

TFESIs should be considered as part of a comprehensive pain management approach that includes physical therapy, patient education, and appropriate medication management 1.