What is the protocol for administering a transforaminal epidural (TFE) injection?

Transforaminal Epidural Injection Protocol

Mandatory Pre-Procedure Requirements

Transforaminal epidural steroid injections must be performed with fluoroscopic guidance to confirm correct needle position and contrast spread before injecting any therapeutic substance. 1, 2

Patient Selection Criteria

• Radicular pain must radiate below the knee (for lumbar) or demonstrate clear dermatomal distribution (for cervical) 2, 3
• MRI evidence of nerve root compression or moderate to severe disc herniation correlating with clinical symptoms 2, 3
• Failed conservative treatment for at least 4 weeks, including physical therapy 2
• Clinical examination findings consistent with radiculopathy (decreased sensation, positive straight leg raise, motor weakness) 2

Absolute Contraindications

• Non-radicular axial spine pain alone - this is a strong contraindication per 2025 BMJ guidelines 1, 3
• Absence of imaging-confirmed nerve root pathology 2, 3

Procedural Protocol

Image Guidance Requirements

Fluoroscopy is mandatory for all transforaminal approaches - this represents current standard of care and is non-negotiable 1, 2, 4. The imaging serves to:

• Confirm correct needle position at the target foramen 1, 2
• Identify intravascular placement before injection (contrast should be injected first) 5
• Document ventral epidural spread of contrast 5
• Avoid catastrophic vascular injury to radicular arteries 6

Injection Technique

Standard injectate composition:

• Local anesthetic: 0.125% bupivacaine, 3-5 mL 4, 5
• Corticosteroid: Triamcinolone 40 mg or methylprednisolone 80 mg 4, 5

Critical safety steps:

1. Inject 1 mL contrast (iopamidol/Isovue) first to confirm epidural placement and rule out intravascular uptake 6, 5
2. Aspirate before injecting therapeutic agents 5
3. Monitor for immediate adverse reactions during and 1-2 minutes post-injection 6

Multi-Level Considerations

For patients with multi-level pathology, two-level TFESIs can be performed in a single session, particularly for paracentral/subarticular disc herniations where response rates reach 66% 7. However, target the most symptomatic level first if performing single-level injection 7.

Critical Safety Warnings

Catastrophic complications, though rare, include spinal cord infarction, paralysis, and death 1, 6. The transforaminal approach carries higher risk than interlaminar approaches due to proximity to radicular arteries 1, 6.

Documented Complications

• Spinal cord vascular infarction with permanent paraparesis 6
• Cauda equina syndrome 3
• Dural puncture, insertion-site infections, sensorimotor deficits 2, 4
• Retinal complications 2, 4

Patients with previous spinal surgery may be at increased risk for complications and technical difficulty 6.

Shared Decision-Making Requirements

Before proceeding, explicitly discuss with patients:

• The specific risks of transforaminal approach versus interlaminar alternatives 1
• Expected benefit: approximately 58-78% achieve ≥50% pain relief at 3 months 5, 8
• Duration of effect: typically 2 weeks to 6 months 1, 8
• Need for repeat injections (average 1.8-1.9 procedures annually) 5
• Alternative approaches available (parasagittal interlaminar has equivalent efficacy with potentially better safety profile) 5

Post-Procedure Protocol

• Monitor patient for 1-2 minutes immediately post-injection for acute neurological changes 6
• Assess response at 2 weeks, then monthly intervals 5, 7
• Responders are defined as ≥50% pain reduction or ≥40% improvement in functional scores 7
• Maximum of 3 injections per year; only repeat if pain returns after documented positive response 5

Integration with Multimodal Care

TFESIs must be part of comprehensive pain management, not standalone treatment 1, 2. Continue concurrent:

• Physical therapy 2, 4
• Appropriate oral analgesics 2
• Patient education and psychosocial support 2