What is a Transforaminal Epidural Steroid Injection (TFESI)?
A transforaminal epidural steroid injection (TFESI) is a fluoroscopically-guided interventional procedure that delivers corticosteroids and local anesthetic directly into the epidural space through the neural foramen, targeting the specific nerve root causing radicular pain. 1
Technical Procedure
TFESI is performed under fluoroscopic guidance with specific technical requirements:
The needle is inserted at a predetermined angle toward the superior-anterior aspect of the neural foramen, with the C-arm fluoroscope positioned for optimal visualization at angles that vary by spinal level. 2
Both anteroposterior (AP) and lateral fluoroscopic views must be obtained to confirm needle tip position at the superior-anterior aspect of the foramen before injection. 2
Contrast dye is injected first to confirm proper epidural spread along the nerve root and rule out intravascular placement before therapeutic injection. 2
The therapeutic injection consists of corticosteroid mixed with local anesthetic, typically delivered after confirming negative intravascular flow and appropriate contrast spread pattern. 2
Fluoroscopic guidance is non-negotiable and considered the gold standard for all transforaminal epidural injections to ensure accurate needle placement and minimize complications. 2, 3
Clinical Indications
The American Society of Anesthesiologists and recent BMJ guidelines provide clear criteria for when TFESI is appropriate:
TFESI is strongly recommended specifically for radicular pain or radiculopathy, not for axial back pain alone. 1, 4
Patients must have radicular pain radiating below the knee with corresponding MRI evidence of nerve root compression from disc herniation, spinal stenosis, or post-surgical changes. 2, 4
Conservative treatment failure for at least 4-6 weeks is required, including physical therapy, NSAIDs, and activity modification before considering TFESI. 2, 3
Strong recommendations exist in favor of fluoroscopically-guided lumbar transforaminal epidural injections for chronic spine pain associated with disc herniation, spinal stenosis, axial discogenic pain, and post-surgery syndrome. 1
Contraindications and Inappropriate Use
Recent guidelines provide strong recommendations against TFESI in specific scenarios:
The 2025 BMJ guideline provides a strong recommendation AGAINST epidural injections for chronic axial spine pain without radiculopathy, stating "all or nearly all well-informed people would likely not want such interventions." 2, 4
The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain, as evidence for benefit is limited. 2, 4
TFESI should not be performed for mechanical back pain from spondylosis, facet arthropathy, or sacroiliac joint pathology in the absence of true radiculopathy. 4
Risks and Complications
TFESI carries a higher risk profile than interlaminar approaches and requires specific informed consent:
Common complications include dural puncture, insertion-site infections, sensorimotor deficits, cauda equina syndrome, discitis, epidural granuloma, and retinal complications. 2, 3
Rare but catastrophic complications include paralysis, spinal cord infarction, and death, which can occur at any spinal level despite proper technique. 1, 2
Shared decision-making must include explicit discussion of these serious complications before proceeding with the procedure. 2, 3
Efficacy and Repeat Injections
Evidence supports specific criteria for determining treatment success and appropriateness of repeat injections:
Repeat TFESI with steroid is appropriate only if the initial injection resulted in at least 50% pain relief lasting at least 2 months. 2, 3
Research demonstrates that 59% of patients with discogenic pain and 35% of patients with spinal stenosis achieve greater than 50% improvement at one year. 5
The transforaminal approach produces better short-term pain improvement and fewer long-term surgical interventions compared to interlaminar epidural injections for symptomatic lumbar disc herniation. 6
Mean duration of injection effect is approximately 12.5 months, with the most effective period being the first 5 months post-injection. 7
Multimodal Treatment Context
TFESI should never be used as monotherapy:
Epidural steroid injections must be provided as part of a comprehensive pain management program that includes physical therapy, patient education, psychosocial support, and oral medications. 2, 3
The procedure is intended to provide temporary symptomatic relief to facilitate participation in rehabilitation, not as maintenance therapy for chronic pain. 3