What spinal levels should be targeted when performing epidural steroid (ES) blocks for patients with lumbar or cervical radiculopathy?

Target Spinal Levels for Epidural Steroid Blocks

Lumbar Radiculopathy

For lumbar radiculopathy, target the specific symptomatic nerve root level using transforaminal approach at the level of pathology demonstrated on MRI (e.g., L5 nerve root for L4-L5 disc herniation, S1 nerve root for L5-S1 disc herniation). 1, 2

Level Selection Criteria

• Match the injection level to the dermatomal distribution of radicular symptoms - pain radiating below the knee in a specific nerve root pattern determines the target level 1
• Correlate clinical symptoms with MRI findings showing nerve root compression at the corresponding level 1
• Use transforaminal approach for single-level pathology as evidence is strong for short-term relief and moderate for long-term relief in lumbar nerve root pain 2, 3

Technical Considerations for Lumbar Levels

• Position needle tip just caudad to the pedicle at 6 o'clock in AP view and at the mid or ventral aspect of the foramen in lateral view 4
• Limit contrast/injectate volume to 0.2-0.4 mL maximum to maintain selectivity at the target level - volumes above 0.6 mL lose selectivity in 67% of cases 4
• Expect superior spread more commonly than inferior spread at both L4 (50%) and L5 (64.7%) levels, which affects level selection strategy 4

Cervical Radiculopathy

For cervical radiculopathy, target the specific symptomatic nerve root level using transforaminal or interlaminar approach at the level of MRI-confirmed pathology. 3

Level Selection for Cervical Spine

• Use cervical transforaminal epidural injections with moderate evidence for managing cervical nerve root pain 3
• Cervical interlaminar approach has moderate evidence for short-term and long-term relief in cervical radiculopathy 3

Critical Contraindications by Level

Do NOT perform epidural steroid injections for:

• Chronic axial spine pain without radiculopathy at any level - strong recommendation against this practice 5
• Non-radicular low back pain - explicitly not indicated regardless of level 1
• Spinal stenosis without significant radicular symptoms - recommended against at all levels 1

Safety Requirements for All Levels

• Mandatory fluoroscopic guidance for all transforaminal and interlaminar approaches to ensure correct needle placement 1, 4
• Document specific level targeted based on clinical examination, dermatomal pain pattern, and MRI correlation 1
• Counsel patients about catastrophic risks including paralysis, spinal cord infarction, and death that can occur at any level 6, 7

Common Pitfalls in Level Selection

• Avoid multi-level injections without documented benefit - repeat injections require ≥50% pain relief for ≥2 weeks from prior injection 1
• Do not rely solely on imaging findings - 85% of chronic spine pain is non-specific and incidental findings are common 5
• Recognize that even 0.2 mL volumes spread beyond target level in 21% of cases, so perfect selectivity is unattainable 4