Fluoroscopic Guided Sacral Transforaminal Epidural Steroid Injection – Technique and Overview

Name of Procedure

• TFESI – Sacral transforaminal (TF) epidural steroid injection (ESI) (diagnostic or therapeutic)
• Selective nerve root block (SNRB)

For a LUMBAR or THORACIC transforaminal epidural injection, see our related article.

Sample Opnote

Goal

To access and then administer medication (such as local anesthetic or steroid) to the epidural space via a transforaminal approach to target specific nerve roots.

Indications

Usually to treat degenerative disc disease or neural foraminal stenosis that is causing radicular symptoms into the torso (thoracic) or legs (lumbar and sacral).

Contraindications

• Common contraindications

Anatomy

coming soon…

Equipment/Skills/Setup

Core Equipment/Disposables: See our disposables/equipment article for “core” items that are common to all procedures.

Core Skills: See our guides to obtain images of the cervical, thoracic, or lumbar spine. Then steer a needle to direct it under the skin.

Special items and suggested setup for this procedure (see quick guide video above for example tray prep):

1. 22g x 3.5″ (or 5″) quincke needle
2. 2cc 0.125% bupivacaine + 1cc steroid in 3cc syringe (about 1.5cc injectate per nerve root) (dexamethasone is low particulate and usually a good choice)
3. contrast in 3cc syringe
4. 5cc 1% lidocaine in 5cc syringe with 25g x 1.5″ hypodermic needle for subcutaneous local anesthetic

Landmarks and Patient Positioning

Position the patient in a basic prone position so that the bottom of the c-arm can go under the table below the area of the spine that is being treated.

Technique

1. Get an AP view of the target level.
   1. You’ll usually need to tilt the c-arm cephalad quite a bit to get good views of the sacral foramina.
   2. Bowel gas can obscure your view: Look for symmetry to identify the left and right foramen and adjust your tilt to get an “open” view of the foramina
2. A mostly “down-the-barrel” approach should work.
   1. However, in the image below the needle takes a slight inferior-to-superior approach.
3. Insert a STRAIGHT quincke needle targeting the superior lip (bone) of the sacral foramen
   1. A bent needle could be used but a straight needle seems to allow easier entry into the foramen in the authors’ experience.

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4. Walk off bone inferiorly aiming towards the lucency of the foramen. Once you feel it walk off bone advance a few millimeters.
5. Inject a small amount of contrast to confirm spread:
   1. Note the curved medial and superior spread along the nerve root.
   2. Use live fluoro or digital subtraction to exclude vascular uptake.

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6. Inject the desired injectate based on the specific procedure (ie, local anesthetic only, or steroid, or both).