What is the recommended first‑line fluoroscopically guided epidural steroid injection (ESI) regimen for a patient with symptomatic lumbar disc herniation causing radicular pain, including drug choice, dose, injection approach, maximum frequency, contraindications, and adjustments for diabetes?

Fluoroscopically Guided Epidural Steroid Injection for Lumbar Disc Herniation

For symptomatic lumbar disc herniation with radicular pain, perform a fluoroscopically guided transforaminal epidural steroid injection (TFESI) using 80 mg methylprednisolone mixed with 2 mL of 0.5% bupivacaine diluted in 8 mL normal saline, with a maximum frequency of one injection every 2 months if prior injection provided ≥50% pain relief for ≥2 months. 1

Patient Selection Criteria

Before proceeding with ESI, verify the following mandatory requirements:

• Pain characteristics: Pain and/or numbness radiating below the knee (not just to the thigh or buttock) 2, 1
• Failed conservative therapy: Minimum 4-6 weeks of NSAIDs, activity modification, and physical therapy 2, 3
• MRI correlation: Imaging within 24 months demonstrating nerve root compression or moderate-to-severe disc herniation that anatomically corresponds to the radicular distribution 2, 3, 1
• Clinical examination: Positive straight leg raise test and/or decreased sensation in dermatomal distribution 2

Critical exclusion: Do NOT perform ESI for axial back pain without true radiculopathy—the American Academy of Neurology explicitly recommends against this, and the 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain 2, 1

Drug Choice and Dosing

The standard regimen based on clinical evidence:

• Steroid: Methylprednisolone 80 mg 4
• Local anesthetic: Bupivacaine 0.5%, 2 mL 4
• Diluent: Normal saline 8 mL (total injection volume 10 mL) 4

This formulation achieved an 81% success rate in symptomatic herniated disc patients at 6-month follow-up 4

Injection Approach Selection

Transforaminal approach is superior to interlaminar for disc herniation 5:

• TFESI provides better short-term pain improvement (70% of patients achieved ≥2-point VNRS reduction vs. 45% with interlaminar) 5
• TFESI results in lower surgical rates at 1 year (10% vs. 25% with interlaminar) 5
• TFESI delivers medication directly to the ventral epidural space and affected nerve root 6

Interlaminar approach may be considered when:

• Transforaminal access is anatomically difficult
• Patient has multilevel pathology requiring broader medication distribution 6

Procedural Requirements

Mandatory Fluoroscopic Guidance

All epidural injections must be performed under fluoroscopy—this is non-negotiable 2, 3, 1:

• Obtain AP and lateral views to confirm needle tip position at the superior-anterior aspect of the neural foramen 2
• Inject contrast to confirm epidural spread along the nerve root and exclude intravascular placement 2
• Document final needle position and contrast pattern 2

Sterile Technique

• Maintain strict sterile technique throughout the procedure 2
• Use appropriate skin preparation and sterile draping 2

Maximum Frequency and Repeat Injection Criteria

Strict criteria govern repeat injections 1:

• First repeat injection: Only if initial injection provided ≥50% pain relief for ≥2 weeks 1
• Subsequent injections: Only if prior injection provided ≥50% pain relief for ≥2 months 1
• Do NOT perform maintenance injections without documented objective benefit—this exposes patients to unnecessary risk 2

If inadequate response after 1-2 injections:

• Evaluate for alternative pain generators (sacroiliac joint, facet-mediated pain, peripheral nerve entrapment) 2
• Consider surgical consultation if progressive neurologic deficit or severe functional impairment 3

Absolute Contraindications

• Non-radicular axial back pain (pain not radiating below the knee) 2, 1
• Active systemic or local infection 2
• Coagulopathy or therapeutic anticoagulation that cannot be safely held 2
• Patient refusal after informed consent discussion 2

Diabetes Management Adjustments

Critical counseling for diabetic patients:

• Expect blood glucose elevation for 2-7 days post-injection 2
• Increase frequency of glucose monitoring for 1 week post-procedure 2
• May require temporary adjustment of insulin or oral hypoglycemic dosing 2
• Consider endocrinology consultation for brittle diabetics or HbA1c >8% 2

Mandatory Shared Decision-Making Discussion

Before proceeding, counsel patients about these specific risks 2, 3:

• Common complications: Transient pain increase, vasovagal response, non-specific headache 2
• Serious complications: Dural puncture with post-dural puncture headache, insertion-site infection, sensorimotor deficits 2, 3
• Rare catastrophic complications: Cauda equina syndrome, discitis, epidural granuloma, retinal complications, paralysis, spinal cord infarction, death 2, 3
• Transforaminal-specific risks: Higher risk profile than interlaminar approach due to proximity to radicular artery 2, 3

Multimodal Treatment Context

ESI is NOT a standalone treatment 2, 1:

• Continue physical therapy focusing on core strengthening and nerve gliding exercises 2, 1
• Maintain patient education about activity modification and proper body mechanics 2, 1
• Optimize oral analgesics (NSAIDs, neuropathic pain medications) as appropriate 2, 1
• Address psychosocial factors and provide appropriate support 2, 1

Expected Outcomes and Follow-Up

• Short-term efficacy: 77% of surgical candidates avoided surgery at 1.5-year follow-up 7
• Pain relief duration: Typically 2 weeks to 27 months, with most benefit in first 3 months 2, 7
• Follow-up timing: Assess response at 2-4 weeks post-injection 3
• Functional improvement: Monitor using validated outcome measures (Oswestry Disability Index, Visual Analog Scale) 4

Common Pitfalls to Avoid

• Do NOT inject without fluoroscopy—blind injections have unacceptable complication rates and poor efficacy 2, 1
• Do NOT repeat injections based solely on patient request—require objective evidence of prior benefit (≥50% relief for ≥2 months) 1
• Do NOT ignore alternative diagnoses—if 3 of 6 sacroiliac joint provocation tests are positive, consider diagnostic SI joint injection instead 2
• Do NOT use ESI as a "bridge to surgery"—if surgery is already planned, the injection adds risk without changing management 2
• Do NOT perform for spinal stenosis without radiculopathy—multiple guidelines explicitly recommend against this 2, 1