Name of Procedure
- TFESI – Lumbar or thoracic transforaminal (TF) epidural steroid injection (ESI) (diagnostic or therapeutic)
- Selective nerve root block (SNRB)
The Quick Guide
Click on the right for the next step, hold down to pause, click left for previous step.
The 2-Minute Lumbar Transforaminal Epidural by theprocedureguide on Jumprope.
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.
Usually to treat degenerative disc disease or neural foraminal stenosis that is causing radicular symptoms into the torso or legs.
See our disposables/equipment article for “core” supplies that are common to all procedures. Highlights below:
- Core Equipment
- c-arm, c-arm compatible bed
- Core Disposables
- Procedure tray. As outlined in the above link, core supplies include a pointer, syringes for subcutaneous local, syringe for injectate, drape.
Special items and suggested setup for this procedure (see quick guide video above for example tray prep):
- 22g x 3.5″ (or 5″) quincke needle
- 3cc 0.125% bupivicaine with steroid in 3cc syringe (about 1.5cc injectate per nerve root) (dexamethasone is low particulate and usually a good choice)
- 3cc contrast in 3cc syringe
- 5cc 1% lidocaine in 5cc syringe with 25g x 1.5″ hypodermic needle for subcutaneous local anesthesia
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.
- Get a basic scotty dog view of the target level (An AP view can also work).
- Line up and anesthetize an entry point about 2cm lateral and 2cm inferior to the infero-lateral tip of the transverse process.
- This gives you a trajectory that aims superior/medial/posterior, which helps get into the transforaminal space nicely.
- Insert a bent quincke needle targeting a landing at the inferior border of the transverse process, just lateral to where it joins the pedicle.
- From here, aim inferior and medial, and “walk” the needle off the bone.
- As soon as it walks off you should be medial and posterior enough to be in the transforaminal space.
- Sometimes it will need to be advanced slightly, but be careful to advance in very slight increments to avoid a paresthesia.
- Inject a small amount of contrast to confirm spread:
- Note the spread rounded under the pedicle, outlining the nerve root. This is typical spread but sometimes it doesn’t outline perfectly and instead you’ll just see medial spread over a wide area like with an interlaminar injection
- Injection under live fluoro or use of digital subtraction can help to make sure that you don’t see contrast uptake
- Inject the desired injectate based on the specific procedure (ie, local anesthetic only, or steroid, or both).
- A combination of experience, patient size and trajectory help you to determine depth. With the approaches mentioned above you usually don’t need a lateral to determine depth.
- While several steering techniques can usually be used, a sharp needle bend is useful here:
- As noted above, after contacting the TP initially, you’ll walk off and under the TP to get into the transforaminal space.
- This is often a short travel distance and so you want the needle to be easily steerable and to steer a lot over a short distance.