CT-guided transforaminal epidural steroid injections: do needle position and degree of foraminal stenosis affect the pattern of epidural flow?

Skeletal Radiol. 2018 Dec;47(12):1615-1623. doi: 10.1007/s00256-018-3002-9. Epub 2018 Jun 18.


Objective: To determine the effect of needle position and foraminal stenosis on contrast flow directionality during CT-guided transforaminal epidural steroid injections (TFESI).

Materials and methods: One hundred five consecutive CT-guided injections were performed in 68 patients (mean age, 65.5 years) from January 1 to December 31 2017, all with preceding MRI. Two readers independently reviewed CT images to assess needle position and to determine direction of contrast flow, which was defined as central or peripheral. The MRIs were independently reviewed by the readers to determine the degree of foraminal stenosis. Inter-reader agreement for both was evaluated with the kappa statistic. Analyses were performed to determine effect of needle position, degree of foraminal stenosis, and volume of contrast injected with directionality of contrast flow, and association between contrast flow directionality with immediate post-procedural pain scores.

Results: Central direction of contrast flow was demonstrated in 41/78 (52.6%) of cases with posterolateral needle position, and 20/27 (74.1%) with central or anteromedial needle position (p = 0.07). There was no difference in direction of contrast flow with high-grade versus absence of high-grade neuroforaminal narrowing, or with volume of contrast injected. There was no difference in immediate post-procedure pain scores regardless of contrast flow directionality.

Conclusions: Needle position is not significantly associated with contrast flow directionality during CT-guided TFESI, although there was a trend towards relatively decreased central flow with posterolateral positioning. Degree of foraminal stenosis and volume of injected contrast did not affect contrast flow directionality. There was no difference in immediate post-procedural pain scores with either direction of contrast flow.

Keywords: CT guidance; Epidural; Injections; Intervention; Spine; Transforaminal.

MeSH terms

  • Adult
  • Aged
  • Anesthetics, Local / administration & dosage
  • Back Pain / drug therapy*
  • Contrast Media / administration & dosage
  • Female
  • Humans
  • Injections, Epidural*
  • Iohexol / administration & dosage
  • Lidocaine / administration & dosage
  • Magnetic Resonance Imaging
  • Male
  • Middle Aged
  • Pain Management
  • Pain Measurement
  • Radiography, Interventional / methods*
  • Retrospective Studies
  • Spinal Stenosis / complications*
  • Steroids / administration & dosage*
  • Tomography, X-Ray Computed / methods*
  • Treatment Outcome


  • Anesthetics, Local
  • Contrast Media
  • Steroids
  • Iohexol
  • Lidocaine