Lumbar Transforaminal Epidural Steroid Injection—Supraneural (Traditional) Approach

Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study

“…Ever y injection was performed by the same boardcertified pain medicine physician. The traditional 'safe triangle' approach described in the well-known text by Berkwits et al [23] was used for every subject. In brief, following local infiltration with 3 mL of 1% lidocaine hydrochloride, a 12.7-cm long, 22-gauge spinal needle was advanced towards the 6 o'clock position of the pedicle until bone was touched.…”

The Kumar Technique: A Novel and Effective Approach to Transforaminal Epidural Steroid Injections

“…Proper TFESI technique delivers steroids at the site of pathology while minimizing the risk of nerve or vessel damage. The traditional supraneural approach to TFESI utilizes the "safe triangle" for injection, which avoids trauma to the exiting nerve root by placing the needle in the anterosuperior aspect of the intervertebral foramen [8,23]. A rare but potentially catastrophic complication is the injection of the radicular arteries, especially the artery of Adamkiewicz, which can result in spinal cord infarction [8,24].…”

“…Transforaminal epidural steroid injections (TFESIs) are the most commonly used option and considered more efficacious than a caudal or interlaminar approach for treating radicular pain, likely due to the TFESI's needle tip placement resulting in better ventral spread of medication during injection [6][7][8]. The American Society of Interventional Pain Physicians have given TFESIs Level 1 evidence in the treatment of lumbar radicular pain from disc herniations, and other studies have shown they are effective in treating additional sources of lower back pain, including postherpetic neuralgia [9,10].…”

Pro-Con Debate: Superior Versus Inferior Triangle Needle Placement in Transforaminal Epidural Injections

“…The superior triangle approach was developed with the intent to minimize risk of damage to the exiting nerve root, as well as avoid intrathecal puncture and vascular injection. [16][17][18] Anatomically, it is a right triangle comprised by the transverse line from the "6 o'clock" position on the pedicle to the lateral pedicular line (upper border), the sagittal line from the lateral pedicle to the imagined exiting spinal nerve (lateral border), and the imagined superior border of the exiting spinal nerve root (hypotenuse) (Figure). In the traditionally described approach, the needle is advanced to the dorsal periosteum of the vertebral body, anterior to the nerve, allowing for medication administration in the anterior epidural space.…”

“…30 However, placement of the needle within posterior-superior aspect of the vertebral foramen, within the superior triangle, can also be used to access the epidural space, thus reducing the risk of intravascular trespass. 18,30,31 An observational study found that the degree of pain relief with the needle placement in the posterolateral epidural space was not significantly different from the conventional approach, and elicited significantly less procedural pain. 31 A comparative trial of 50 patients evaluating the conventional approach via the anterior-superior quadrant of the foramen versus a posterolateral approach via the posterior-superior quadrant found no significant differences in pain or disability outcome measures, intravascular injection, or dural puncture, as detected by real-time fluoroscopy.…”