Trends in lumbar epidural injection selection: A survey of practitioner preferences and practice patterns

Lumbar radiculopathy is estimated to affect approximately 3-5 % of the population. Among the leading causes of radiculopathy are degenerative or congenital spinal stenosis and lumbar disc herniations, which can contribute to compression and narrowing in various regions of the spine including the neural foramen, subarticular recess, or central canal. When patients do not respond to typical conservative treatment such as medications and physical therapy, epidural steroid injections can be considered as a next step in management. There are three approaches available for accessing the lumbar epidural space: caudal, interlaminar, and transforaminal. There is no clear consensus regarding the selected approach for an epidural injection based on a patient's history, physical examination, and imaging findings, however.

The purpose of this study was to explore how factors such as primary residency training, fellowship training, practice setting, adherence to IPSIS guidelines, geographic location, and years of experience may influence epidural approach preferences.

A survey was created utilizing the Survey Monkey™ platform which was then administered by the International Pain and Spine Intervention Society (IPSIS) to all active members via email. The survey consisted of seven questions asking for demographic information including residency specialty, fellowship training, if the fellowship emphasized IPSIS guidelines, years in practice, country of practice, and practice setting. There were questions that described hypothetical clinical scenarios that provided the respondent with the pain distribution and the associated pertinent magnetic resonance imaging (MRI) findings. For each scenario, the responder was given options for type of therapeutic injection the practitioner would choose. The final two questions then asked which steroid the responder would utilize for an interlaminar and transforaminal epidural steroid injection. The survey was open for completion during a three-month period. A total of 202 IPSIS members responded, with an average of 196 responses to each question with a completion rate of 74 %.

Most respondents completed residency in Physical Medicine and Rehabilitation (63.1 %) or Anesthesiology (29.9 %), with 67.7 % reporting fellowship training aligned with IPSIS guidelines. The most common fellowship type was ACGME-accredited pain (38.6 %), and respondents were primarily based in the U.S. (84.8 %), practicing in private multi-specialty groups (35.5 %). Experience levels were well distributed, with most in either early (<5 years, 32.1 %) or late-career (>15 years, 34.7 %) stages. Across all six clinical scenarios, the transforaminal supraneural approach was most frequently selected, especially at L4-L5 and L5-S1. Respondents selecting the most common techniques were primarily PM&R-trained and fellowship-trained in ACGME pain programs using IPSIS-guided approaches, with a balanced distribution across years in practice. Dexamethasone was the most frequently used steroid for both interlaminar (35.1 %) and transforaminal (71.1 %) epidural injections. Providers selecting dexamethasone were again predominantly PM&R-trained, IPSIS-guided, and either early or late career.

Symptom distribution, particularly radicular pain, strongly influenced the choice of transforaminal supraneural injections, underscoring the primacy of clinical presentation over imaging alone. The predominant use of dexamethasone reflects a broader shift toward safety-oriented protocols. Overall, provider training and practice setting were more predictive of decision-making than clinical scenario complexity, highlighting the need for continued education across all provider types.