Follow-Up Protocol After Lumbar Transforaminal Epidural Steroid Injection
Initial Post-Procedure Contact
.PatientName. received lumbar transforaminal epidural steroid injection on .Date. under fluoroscopic guidance for treatment of radicular pain.
First follow-up call scheduled within 1 week post-procedure to assess immediate response, injection site tolerance, and adverse effects. 1, 2
One-Week Telephone Assessment
- Contact patient at 7 days post-injection to evaluate:
- Injection site reactions (erythema, swelling, drainage) 1, 2
- Immediate adverse effects including new sensorimotor deficits, bowel/bladder dysfunction, or severe headache suggesting dural puncture 1, 2, 3
- Current pain level on 0-10 numerical rating scale (NRS) compared to pre-procedure baseline 4, 5
- Presence or absence of immediate anesthetic response (noting that immediate pain relief does NOT predict 2-month outcomes) 4
Document that immediate post-procedure pain response has weak predictive value (C-index 0.58) for longer-term effectiveness. 4
Two-Week In-Person or Telehealth Visit
The 2-week assessment is critical as response at this timepoint strongly predicts 2-month outcomes (C-index 0.77 for pain, 0.80 for function). 4
Required Assessments at 2 Weeks
- Pain NRS score (0-10 scale) 4, 5
- Oswestry Disability Index (ODI) or Roland-Morris Disability Questionnaire 4, 5
- Medication usage changes, particularly opioid requirements 6
- Return to work status and functional activities 6
- Physical examination for dermatomal sensory changes and motor strength 2
Define treatment success at 2 weeks as ≥50% reduction in NRS or ≥40% reduction in ODI. 4, 5
Patients responding at 2 weeks are 6.49 times more likely to be responders at 2 months compared to non-responders. 4
Two-Month Follow-Up Visit
Schedule comprehensive reassessment at 8 weeks post-injection as this represents the primary outcome timepoint for determining injection efficacy. 4, 5, 7
Required Documentation at 2 Months
- Pain NRS score with comparison to baseline and 2-week values 4, 5
- ODI score with ≥40% reduction defining functional success 4, 5
- Current medication regimen including opioid use 6
- Employment status and ability to perform activities of daily living 6
- Recurrence of radicular symptoms below the knee 2, 3
Expected success rates: 57.7% achieve ≥50% pain reduction and 51.7% achieve ≥40% functional improvement at 2 months. 5
Decision Algorithm for Repeat Injection
Repeat TFESI with steroid is appropriate ONLY if the initial injection provided at least 50% pain relief lasting at least 2 months. 2, 3
Criteria for Repeat Injection (All Must Be Met)
- Documented ≥50% pain relief from initial injection 2, 3
- Duration of relief lasted ≥2 months (Spine Intervention Society criteria) 2, 3
- Recurrent radicular pain below the knee (not axial back pain alone) 1, 2, 3
- MRI findings still correlate with clinical symptoms 1, 3
- Patient remains part of comprehensive multimodal treatment program including physical therapy 2, 3
Do NOT repeat injections based solely on patient request without objective evidence of prior benefit lasting at least 2 months. 1
Long-Term Monitoring Considerations
Counsel patients that despite initial success, 76.9% experience recurrent symptoms within 5 years, though only 23.1% have current pain at 5-year follow-up. 6
Long-Term Outcomes to Discuss
- High recurrence rate (77%) over 5 years despite initial success 6
- Low rate of chronic opioid use (7.7%) at 5 years 6
- Surgery rate of 48.7% within 5 years for those with persistent symptoms 6
- Only 7.7% unemployed due to pain at 5-year follow-up 6
Red Flags Requiring Urgent Evaluation
Instruct patient to seek immediate evaluation for:
- New or progressive lower extremity weakness 1, 2, 3
- Bowel or bladder dysfunction (cauda equina syndrome) 1, 2, 3
- Severe headache with neck stiffness (meningitis or dural puncture) 1, 2
- Fever with back pain (discitis or epidural abscess) 1, 2
- Sudden vision changes (retinal complications) 1, 2
Documentation Template
.PatientName. returns for follow-up after TFESI performed on .Date. at .Level. under fluoroscopic guidance.
Current pain NRS: .Score./10 (baseline .Score./10,2-week .Score./10)
Current ODI: .Score.% (baseline .Score.%, 2-week .Score.%)
Treatment response: [Responder ≥50% pain relief / Non-responder <50% relief]
Medication changes: [Reduced/unchanged/increased opioids]
Functional status: [Improved/unchanged/declined] - specific activities documented
Plan: [Continue multimodal therapy / Consider repeat injection if criteria met / Refer for surgical evaluation if progressive deficits or inadequate response]