Epidural steroid injection is a safe outpatient procedure, which is performed best using image guidance in conjunction with epidurography. Using the techniques described earlier, complications are minimized, and serious complications can be avoided, in experienced hands. The author has performed several thousand procedures in an outpatient setting without any serious complications. Optimal safety and efficacy require an excellent working knowledge of the radiographic anatomy, and the imaging equipment used to perform these procedures. Several studies have demonstrated the difficulty and uncertainty of obtaining an accurate injection without imaging guidance. Radiologists who are well trained in the performance of image-guided percutaneous injection procedures are thus armed with the background to perform these procedures in a safe and efficacious manner. In addition, referral of these procedures to a third party (radiologist) without economic incentives reduces the potential abuse of self-referral--which may occur (or be suspected by payors) when the primary clinician recommends, and then performs, pain management procedures. The use of sedation to perform these procedures is unnecessary, and deep sedation may be dangerous when injections are performed in the vicinity of the spinal cord. The author's experience, which includes clinical feedback and formal trials, shows the technique described in this article to be performed safely without sedation in an outpatient setting, with a high success rate for alleviating pain symptoms. When properly performed, epidural steroid injections have a clinically established role in the management of neck and back pain.