Alternative approach for lumbar transforaminal epidural steroid injections

The traditional superoanterior approach for transforaminal epidural steroid injection (TFESI) carries a risk of complication by obstructing arterial flow to the anterior portion of the spinal cord by puncturing the spinal radicular artery that passes through the superoanterior foraminal zone or "safe triangle" zone, which does not describe vascular safety, but rather describes neural safety. Consequently, multiple disasters have been described in recent years with transforaminal epidural injections. They are utilized extensively even though their effectiveness has been debated. Here we describe a dorsal technique through transforaminal epidural injections to place the tip of the needle immediately dorsal to the dorsal root ganglion. Multiple different techniques have been discussed and described in recent years, the majority of them to avoid the radicular artery injection. The primary goal of this paper is to describe another posterior approach to place the tip of spinal needle directly toward the posterior epidural space to avoid puncturing the spinal radicular artery and minimize nerve root penetrations while delivering medication into the epidural space through the foramen.