Spinal Injections and Procedures
Core concepts
Know epidural approaches (interlaminar, transforaminal, caudal), facet and medial branch injections, and sacroiliac joint injections. Understand indications, contrast confirmation, and steroid versus anesthetic roles. Transforaminal epidural steroid injection carries unique risk because of radicular artery anatomy.
Technique and safety
Themes: image guidance with contrast, avoiding intravascular injection, recognizing the risk of cord infarction with particulate steroid in the cervical and upper thoracic transforaminal space, anticoagulation management per guidelines, and infection prevention. Epidural hematoma and abscess are emergencies requiring urgent recognition.
Traps
- Assuming all epidural approaches carry equal risk; transforaminal cervical injections are higher risk.
- Overlooking anticoagulant timing before neuraxial procedures.
- Repeated steroid dosing without reassessing benefit.
- Confusing facet joint injection with medial branch block for radiofrequency planning.
Worked rule of thumb
For any neuraxial injection: verify anticoagulation status, confirm needle position with contrast under live imaging, aspirate, and inject incrementally. If contrast shows vascular uptake, reposition before injecting steroid.
Outcomes
Track pain, function, and duration of relief; a short-lived response informs prognosis and whether to escalate to a different intervention.